Prevencion de Consumo de Drogas Ilegales en Escuelas

Prevencin del consumo de drogas ilegales en las escuelas.
Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P

Reproduccin de una revisin Cochrane, traducida y publicada en La Biblioteca Cochrane Plus, 2008, Nmero 2
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NDI CE DE MATERI AS
RESUMEN...................................................................................................................................................................1
RESUMEN EN TRMINOS SENCILLOS....................................................................................................................2
ANTECEDENTES........................................................................................................................................................2
OBJETIVOS.................................................................................................................................................................3
CRITERIOS PARA LA VALORACIN DE LOS ESTUDIOS DE ESTA REVISIN......................................................3
ESTRATEGIA DE BSQUEDA PARA LA IDENTIFICACIN DE LOS ESTUDIOS....................................................4
MTODOS DE LA REVISIN.....................................................................................................................................6
DESCRIPCIN DE LOS ESTUDIOS..........................................................................................................................7
CALIDAD METODOLGICA.......................................................................................................................................9
RESULTADOS...........................................................................................................................................................10
DISCUSIN...............................................................................................................................................................12
CONCLUSIONES DE LOS AUTORES......................................................................................................................14
AGRADECIMIENTOS................................................................................................................................................15
POTENCIAL CONFLICTO DE INTERS...................................................................................................................15
FUENTES DE FINANCIACIN..................................................................................................................................15
REFERENCIAS.........................................................................................................................................................15
TABLAS......................................................................................................................................................................21
Characteristics of included studies.....................................................................................................................21
Characteristics of excluded studies....................................................................................................................41
Table 01 Metodological quality of included studies (CDAG's check list criteria): RCTs......................................43
Table 02 Metodological quality of included studies (CDAG's check list criteria): CPSs......................................45
Table 03 Characteristics of intervention and control arms..................................................................................45
Table 04 Results from RCTs not providing data for meta-analyses (1st part)....................................................46
Table 05 Results from RCTs not providing data for meta-analyses (2nd part)...................................................48
Table 06 Results from CPSs...............................................................................................................................48
Table 07 Summary of results at posttest.............................................................................................................49
Table 08 Summary of results at 1 year follow-up................................................................................................49
Table 09 Summary of results after 2 years follow-up..........................................................................................49
CARTULA................................................................................................................................................................50
RESUMEN DEL METANLISIS.................................................................................................................................51
GRFICOS Y OTRAS TABLAS..................................................................................................................................55
01 conocimiento versus currculo habitual..........................................................................................................55
01 conocimiento sobre las drogas...............................................................................................................55
02 habilidades para la toma de decisiones..................................................................................................55
03 seguridad en s mismo...........................................................................................................................56
04 actitudes hacia la cocana......................................................................................................................56
05 intencin de consumir cocana...............................................................................................................56
02 habilidades versus currculo habitual.............................................................................................................57
Prevencin del consumo de drogas ilegales en las escuelas. i
Copyright John Wiley & Sons Ltd. Usado con permiso de John Wiley & Sons, Ltd.
03 autoestima..............................................................................................................................................57
04 resistencia a la presin de los compaeros...........................................................................................58
05 actitudes hacia las drogas......................................................................................................................58
06 intencin de consumir drogas.................................................................................................................58
07 consumo de drogas................................................................................................................................59
08 consumo de marihuana (todos los estudios)..........................................................................................59
09 consumo de marihuana (slo estudios de calidad A-B).........................................................................59
10 consumo de marihuana..........................................................................................................................60
11 consumo de inhalantes...........................................................................................................................60
12 consumo de inhalantes...........................................................................................................................60
13 consumo de drogas duras......................................................................................................................61
03 habilidades versus conocimiento...................................................................................................................61
04 autoestima..............................................................................................................................................62
05 eficacia individual...................................................................................................................................63
06 intencin de consumir marihuana...........................................................................................................63
04 habilidades versus respuesta afectiva...........................................................................................................64
05 respuesta afectiva versus currculo habitual..................................................................................................64
06 respuesta afectiva versus conocimiento........................................................................................................65
07 tcnica interactiva versus pasiva...................................................................................................................67
04 autoestima..............................................................................................................................................68
08 consumo de marihuana..........................................................................................................................69
09 compaeros versus educadores externos.....................................................................................................70
NDICE DE MATERIAS
ii Prevencin del consumo de drogas ilegales en las escuelas.
04 autoestima..............................................................................................................................................71
NDICE DE MATERIAS
Prevencin del consumo de drogas ilegales en las escuelas. iii
Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P
Esta revisin debera citarse como:
Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P. Prevencin del consumo de drogas ilegales en
las escuelas. (Revisin Cochrane traducida). En: La Biblioteca Cochrane Plus, 2008 Nmero 2. Oxford: Update Software Ltd.
Disponible en: http://www.update-software.com. (Traducida de The Cochrane Library, 2008 Issue 2. Chichester, UK: John Wiley
& Sons, Ltd.).
Fecha de la modicacin ms reciente: 04 de febrero de 2005
Fecha de la modicacin signicativa ms reciente: 08 de febrero de 2005
RESUMEN
Antecedentes
La drogadiccin es una enfermedad crnica y recurrente. Las intervenciones primarias deberan dirigirse a reducir el consumo
inicial o prevenir la transicin del uso experimental a la adiccin. La escuela es el mbito adecuado para las intervenciones
preventivas.
Objetivos
Evaluar la efectividad de las intervenciones realizadas en las escuelas para aumentar el conocimiento, desarrollar habilidades,
promover el cambio y prevenir o reducir el consumo de drogas, versus actividades curriculares habituales o una intervencin
diferente realizada en las escuelas.
Estrategia de bsqueda
Se hicieron bsquedas en MEDLINE , EMBASE, ERIC, PSYCHINFO, Cochrane Library, ACP Journal Club, Cochrane Drug
and Alcohol Group Register, actualizadas hasta febrero 2004. Se veric la bibliografa de los artculos y se establecieron contactos
personales para identicar otros estudios pertinentes.
Criterios de seleccin
ECA, ECC o Estudios Prospectivos Controlados (EPC) que evalen intervenciones realizadas en las escuelas, diseadas para
prevenir el consumo de sustancias.
Recopilacin y anlisis de datos
Dos revisores seleccionaron y extrajeron los datos de forma independiente. La calidad se evalu por medio de la lista de control
del CDAG.
Las intervenciones se clasicaron segn se basaran en las habilidades, la respuesta afectiva o el conocimiento; tambin se
estudiaron otras caractersticas, como educacin, implementacin del seguimiento y activacin del contexto.
Resultados principales
Se incluyeron 32 estudios: 29 ECA y tres EPC. 28 fueron realizados en EE.UU.: la mayora se centr en estudiantes de 6-7
grado y se bas en la evaluacin posterior a la intervencin.
ECA
(1) Conocimiento versus currculo habitual
Los programas basados en la informacin aumentan el conocimiento sobre las drogas (DME = 0,91; IC del 95%: 0,42; 1,39).
(2) Habilidades versus currculo habitual
Las intervenciones basadas en las habilidades aumentan el conocimiento sobre las drogas (DMP = 2,60; IC del 95%: 1,17 a 4,03),
las habilidades para la toma de decisiones (DME = 0,78; IC del 95%: 0,46 a 1,09), la autoestima (DME = 0,22; IC del 95%: 0,03
a 0,40), la resistencia a la presin de los compaeros (RR = 2,05; IC del 95%: 1,24 a 3,42), el consumo de drogas (RR = 0,81;
IC del 95%: 0,64; 1,02), el consumo de marihuana (RR = 0,82; IC del 95%: 0,73; 0,92) y el consumo de drogas duras (RR = 0,45;
IC del 95%: 0,24 a 0,85).
(3) Habilidades versus conocimiento
Pgina 1
No hay diferencias evidentes.
(4) Habilidades versus respuesta afectiva
Las intervenciones basadas en las habilidades son mejores que aquellas basadas en la respuesta afectiva solo en lo que respecta
a la ecacia individual (DMP = 1,90; IC del 95%: 0,25 a 3,55).
(5) Respuesta afectiva versus currculo habitual
Las intervenciones basadas en la respuesta afectiva aumentan el conocimiento sobre las drogas (DME = 1,88; IC del 95%: 1,27
a 2,50) y las habilidades para la toma de decisiones (DME = 1,35; IC del 95%: 0,79 a 1,9).
(6) Respuesta afectiva versus conocimiento
Las intervenciones afectivas aumentan el conocimiento sobre las drogas (DME = 0,60; IC del 95%: 0,18 a 1,03), y las habilidades
para la toma de decisiones (DME = 1,22; IC del 95%: 0,33 a 2,12).
Resultados de los EPC
A partir de los EPC no surge ningn resultado estadsticamente signicativo.
Conclusiones de los autores
Los programas basados en las habilidades parecen ser efectivos para desalentar el consumo inicial de drogas.
La replicacin de los resultados en ensayos aleatorios bien diseados y a largo plazo, y la evaluacin de los componentes
individuales de la intervencin (compaeros, padres, sesiones de apoyo) constituyen las prioridades para la investigacin. Todos
los estudios nuevos deberan controlar el efecto del agrupamiento.
RESUMEN EN TRMI NOS SENCI LLOS

Sinopsis pendiente
ANTECEDENTES
La drogadiccin (consultar el mdulo del CDAG, Amato 2005)
se describe con frecuencia, mdica y socialmente, como una
enfermedad crnica, recurrente, caracterizada por los efectos
del consumo prolongado de la droga misma y por el trastorno
conductual debido a su bsqueda compulsiva (Leshner 1997).
Los consumidores de drogas se dividen habitualmente en
aquellos "que buscan sensaciones" y aquellos que las consumen
"como una manera de lidiar con los problemas de la vida o con
el estado de nimo disfrico". No todos los consumidores se
convierten en adictos. Sin embargo, una vez establecida, la
adiccin "consiste a menudo en una compulsin incontrolable
a buscar y consumir drogas" (Leshner 1999). El uso
experimental afecta principalmente a los adolescentes, que
"consumen drogas simplemente por las sensaciones placenteras
o la euforia que las mismas pueden producir, o para sentirse
aceptados por sus compaeros" (Leshner 1999). Debido a que
no se conocen los factores neurolgicos o psicolgicos que
afectan el riesgo de adiccin, es posible que "aun el consumo
ocasional de drogas resulte inadvertidamente en adiccin"
(Leshner 1997; Leshner 1999). La historia natural de la adiccin
se ha descrito en trminos de una "teora de la puerta de entrada"
("gateway theory)" o una "hiptesis de la pasadera"
("stepping-stone hypothesis)", de modo tal que involucrarse en
el consumo de drogas puede seguir pasos determinados
culturalmente. Por ejemplo, las bebidas de alta graduacin
alcohlica y el tabaco se consideran pasos intermedios entre la
cerveza o el vino y la marihuana, mientras que esta lo es para
otras drogas ilegales (Kandel 1975, Fergusson 2000). Sin
embargo, esta teora no es aceptada universalmente (Morral
2002). Cualquiera sea el modelo de explicacin que se
considere, las intervenciones primarias deberan dirigirse a
reducir el consumo inicial o prevenir la transicin del uso
experimental a la adiccin.
La dependencia a las drogas es un problema complejo, cuya
comprensin requiere un conocimiento profundo de los
determinantes de los trastornos conductuales en un contexto
dado ( Green 1991). Sin embargo la ausencia de un panorama
sucientemente claro de la dinmica y los determinantes del
abuso inicial de drogas, obstaculiza la implementacin de
programas de prevencin efectivos. De hecho, la complejidad
de la cadena causal diculta la aplicacin del pensamiento
basado en la evidencia en la prevencin primaria. Esta cadena
se compone de dos eslabones importantes: el primero es la
relacin entre los factores de riesgo y el problema que debe
prevenirse (p.ej. el papel del hbito de fumar tabaco como causa
del cncer de pulmn); el segundo es la relacin entre la
intervencin preventiva y la reduccin de la conducta riesgosa
(p.ej. la efectividad de un programa de prevencin para reducir
el nmero de jvenes que comienzan a fumar). El conocimiento
sobre el primer eslabn es incierto, si bien estn implicados
factores sociales y psicolgicos, la susceptibilidad, la
informacin acerca de los riesgos y otros factores. La deciencia
Pgina 2
de las teoras acerca de los orgenes de la drogadiccin se debe
en parte a la dicultad para estudiar dichos factores.
Una asociacin positiva entre una intervencin y la reduccin
de la incidencia del consumo de drogas conrma naturalmente
tanto el papel del factor de riesgo en estudio como la efectividad
de la intervencin, mientras que un resultado negativo puede
reejar la identicacin equivocada de un factor de riesgo o la
inecacia de la intervencin.
Muchos programas de prevencin se han basado en el
conocimiento de los factores de riesgo, ya que "un programa
de prevencin que no se base en la comprensin de las
correlaciones y los problemas relacionados con el abuso de
drogas en la juventud sera infortunado desde el comienzo".
Sin embargo, muy pocos se han evaluado adecuadamente: rara
vez se evaluaron mediante ensayos controlados aleatorios y la
evaluacin, con frecuencia, no fue adecuada para medir los
resultados nales.
Las escuelas constituyen un mbito adecuado para los
programas de prevencin del consumo ilegal de drogas por tres
razones: primero, cuatro de cada cinco fumadores de tabaco
comienzan a fumar antes de la edad adulta. Por lo tanto, la
prevencin del consumo de sustancias debe centrarse en nios
en edad escolar y adolescentes, antes de que se establezcan sus
creencias y expectativas acerca del consumo de sustancias.
Segundo, las escuelas ofrecen la manera ms sistemtica y
eciente de acceder a un nmero considerable de jvenes cada
ao. Tercero, en la mayora de los pases, las escuelas pueden
adoptar e imponer un espectro amplio de polticas educativas.
Por estas razones, la mayora de los programas se realizan en
las escuelas. Se utilizan diferentes enfoques: como lo sugiri
Nancy Tobler (Tobler 1986), los programas pueden dividirse
en aquellos basados en: 1.) intervenciones puramente de
conocimiento, donde la descripcin de los efectos biolgicos
y psicolgicos del consumo de drogas se dirige a generar
actitudes negativas hacia las drogas y, en consecuencia, a
disminuir su consumo; 2.) intervenciones sobre la respuesta
afectiva solamente, p.ej. intervenciones para aumentar la
autoestima o la autoconciencia, basadas en la suposicin de que
los factores psicolgicos ponen a las personas en riesgo de
consumo; 3.) intervenciones basadas en los compaeros, por
ejemplo, programas de habilidades de rechazo y de la vida
social; los primeros centrados en las habilidades de resistencia
o tcnicas para "decir No" o en modelos de roles de compaeros,
y los ltimos basados en habilidades interpersonales
(comunicacin, modelos, etc.) o personales (educacin afectiva),
ambos fundamentados en la suposicin de que la presin de los
compaeros puede resultar en el consumo de drogas; 4.)
intervenciones de conocimiento ms la respuesta afectiva, en
las cuales la informacin se combina con la educacin afectiva
para proporcionar valores y crear patrones para la toma de
decisiones; 5.) enfoques alternativos (actividades y
competencia), como las intervenciones que fomentan actividades
alternativas al consumo de drogas o aquellas dirigidas a reforzar
habilidades de control.
Muchos estudios evaluaron la ecacia de los programas de
prevencin del consumo de drogas. En su mayora son ECA,
de calidad variable. Pocos de los estudios no aleatorios son de
alta calidad pero su utilidad es cuestionada (MacMahon 2001).
Algunos autores sugieren su inclusin en las revisiones
sistemticas, siempre que cumplan con un estndar elevado de
calidad.
La evidencia, principalmente en forma de resultados
cualitativos, se resumi en varias ocasiones (Hansen 1992;
Kroger 1994; White 1997; White 1998). Las revisiones ms
signicativas son aquellas realizadas por Tobler (Tobler 1997;
Tobler 2000), que adopt la tcnica de metanlisis de Glass
para estudios sociales (Glass 1981).
Ninguna de estas revisiones evalu exhaustivamente la calidad
del diseo de los estudios, los tipos de intervencin, los
diferentes resultados, la duracin del seguimiento y otras
caractersticas necesarias para saber cual es la forma de
intervencin ms efectiva.
Por lo tanto, el artculo presenta una revisin sistemtica de los
estudios que evalan la efectividad de las intervenciones
realizadas en las escuelas, dirigidas a controlar el consumo
ilegal de drogas.
OBJETI VOS
La evaluacin de la efectividad de las intervenciones realizadas
en las escuelas versus las actividades curriculares habituales o
una intervencin diferente realizada en las escuelas mediante:
- el aporte de conocimientos especcos, el desarrollo de
habilidades especcas o la promocin del cambio en las
actitudes y las conductas;
- la reduccin de la incidencia del consumo inicial, la frecuencia
y la cantidad de sustancias ilegales utilizadas y la prevalencia
de los consumidores entre alumnos de las escuelas primaria o
secundaria.
CRI TERI OS PARA LA VALORACI N DE LOS
ESTUDI OS DE ESTA REVI SI N
Tipos de estudios
Se consideraron todos los estudios que informaron la evaluacin
de cualquier programa de intervencin dirigido a individuos o
a grupos versus una situacin de control (actividades
curriculares habituales u otro programa de prevencin de drogas
realizado en escuelas) y diseado para prevenir el consumo de
sustancias en el mbito escolar.
Para ser incluidos, los estudios deban basarse en un diseo
experimental o semiexperimental, como un Ensayo Controlado
Aleatorio (ECA) o un Ensayo Clnico Controlado (ECC), o en
un diseo observacional bien realizado como los Estudios
Prospectivos Controlados (EPC); tambin deban describir por
completo la intervencin.
Pgina 3
Tipos de participantes
Los alumnos de escuelas primarias o secundarias constituyeron
la poblacin objetivo. Se excluyeron los estudios que se dirigan
a poblaciones especiales.
Tipos de intervencin
Intervencin experimental
Intervenciones realizadas en las escuelas, clasicadas segn
Tobler (Tobler 1997; Tobler 2000), en cuanto a:
los objetivos educativos (programas basados en las
habilidades, la respuesta afectiva o el conocimiento);
la modalidad de enseanza (interactiva, pasiva);
los administradores (profesores regulares, educadores
externos, compaeros);
el seguimiento (con o sin apoyo);
la activacin del contexto (alta o baja).
Intervencin de control
actividades curriculares
una intervencin diferente realizada en la escuela
Tipos de medidas de resultado
Las variables de resultado analizadas en esta revisin fueron
dicotmicas (D) o continuas (C):
(1) conocimiento sobre las drogas (autoinformes, pruebas
especcas - C):
- general
- drogas especcas
(2) actitudes hacia las drogas (autoinformes, pruebas especcas
- C);
- general
- drogas especcas
(3) adquisicin de habilidades personales (autoinformes, pruebas
especcas - C):
- autoestima
- ecacia individual
- habilidades para la toma de decisiones
- resistencia a la presin de los compaeros
- seguridad en s mismo
(4) consumo de drogas por parte de compaeros / adultos
(autoinformes, pruebas especcas - D):
- general
- drogas especcas
(5) intencin de consumir drogas (autoinformes, pruebas
especcas - D):
- general
- drogas especcas
(6) consumo de drogas (autoinformes, pruebas especcas -
C/D):
- general
- drogas especcas
(7) cambios en las conductas (autoinformes, - C/D):
- arrestos
- hospitalizacin
- informes policiales de incidentes
- rendimiento escolar (pruebas especcas - C/D)
Otros factores se consideraron factores de confusin y se
tuvieron en cuenta en el anlisis, cuando fue posible:
- nivel inicial del consumo de drogas
- edad, sexo, origen tnico
- nivel de educacin familiar, estado laboral, ingresos
- posicin social de la familia, nivel de vida
- prevalencia del consumo en amigos, padres
- escuela de ubicacin rural, suburbana o urbana
ESTRATEGI A DE BSQUEDA PARA LA
I DENTI FI CACI N DE LOS ESTUDI OS
Se utilizaron las siguientes fuentes:
- MEDLINE (OVID 1966 - febrero 2004)
- EMBASE (OVID 1988 - febrero 2004)
- ERIC (1988 - febrero 2004)
- SOCIOLOGICAL ABSTRACTS (1963-2000)
- PSYCHINFO (OVID 1967 - febrero 2004)
- Registro Cochrane Central de Ensayos Controlados (Cochrane
Central Register of Controlled Trials, CCTR), 1a actualizacin
en 2004
- ACP Journal Club (OVID 1991 - febrero 2004)
- Base de datos Cochrane de Revisiones Sistemticas (Cochrane
Database of Systematic Reviews, DSR), 1a actualizacin en
2004
- Base de Datos de Resmenes de Revisiones de Efectos
(Database of Abstracts of Reviews of Effects, DARE), 1a
actualizacin en 2004
- Registro del Grupo de Drogas y Alcohol (Register of the drug
and alcohol Group, CDAG), 1a actualizacin en 2004
Para identicar los estudios incluidos en esta revisin se
utilizaron estrategias de bsqueda detalladas para cada base de
datos consultada. Las mismas se basaron en la estrategia de
bsqueda desarrollada para MEDLINE, pero revisada
apropiadamente para cada base de datos para considerar las
diferencias en las reglas de sintaxis y el vocabulario controlado.
No se impusieron restricciones de idiomas.
Registro de Ensayos del Grupo Cochrane de Drogas y
Alcohol (Cochrane Drugs and Alcohol Group) revisado en
febrero de 2004:
"diagnosis=substance abuse and intervention=school-based
prevention"
CENTRAL (nmero 2, 2004):
#1 substance-related disorders:ME
#2 addict*
#3 (abus* or use*)
#4 1 or 2 or 3
#5 morphine:ME
#6 cannabis:ME or cannabis
#7 heroin
#8 hashish
#9 marijuana or marihuana
Pgina 4
#10 n-Methyl-3-4-methylenedioxyamphetamine:ME or ecstasy
or MDMA
#11 hallucinogens:ME or hallucinogen*
#12 cocaine:MESH or cocaine*
#13 lysergic-acid:ME or Lsyergic near acid or lsd
#14 designer-drugs:ME or designer next drugs
#15 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14
#16 4 or 15
#17 Centers for Disease Control and Prevention (U.S.):ME
#18 primary prevention:ME or prevention
#19 health education:ME or
#17 counseling:ME or sex counseling:ME or counseling
#18 peer group:ME or peer group
#19 activities of daily living:ME
#20 adaptation, psychological:ME
#21 adolescent psychology:ME
#22 interpersonal relations:ME
#23 social adjustment:ME
#24 life near skills
#25 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24
#26 16 and 25
MEDLINE (OVID - enero 1966 hasta febrero 2004):
#1 exp substance-related disorders
#2 addict$.ab,ti
#3 (abus$ or use$).ab,ti
#4 1 or 2 or 3
#5 morphine.ab,ti
#6 exp *cannabis/ or "hashish".mp.
#7 heroin.ab,ti
#8 "heroin dependence".mp
#9 exp *n-methyl-3-4-methylenedioxyamphetamine/ or
"ecstasy".mp OR MDMA".mp
#10 exp *hallucinogens/ or "hallucinogens".mp.
#11 exp *cocaine/or exp *crack cocaine/ or "cocaine".mp
#12 exp *lysergic acid diethylamide/ or "lsd".mp.
#13 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
#14 exp *"centers for disease control and prevention (U.S.)"
#15 exp *primary prevention/ or "prevention".mp.
#16 exp *health education/ or "health education".mp.
#17 exp * counseling/ or exp *sex counseling/ or
"counseling".mp.
#18 exp *peer group/ or "peer group".mp.
#19 exp *activities of daily living/ or
#20 exp *adaptation, psychological/
#21 exp *adolescent psychology/
#22 exp *interpersonal relations/
#23 exp *social adjustment/ or "life skills".mp
#24 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23
#25 4 or 13
#26 25 and 24
#27 limit 26 to human
EMBASE (OVID - enero 1988 hasta febrero 2004):
#1 exp illicit drug/
#2 exp drug abuse/ or exp drug dependence/ or exp substance
abuse/
#3 (addict$ or abus$ or use$).ab,ti
#4 1 or 2 or 3
#5 exp morphine derivative or exp morphine
#6 exp diamorphine/
#7 exp *cannabis derivative/ or exp cannabis
#8 (marijuana or marihuana).ab,ti
#9 hashish.ab,ti
#10 exp *n-methyl-3-4-methylenedioxyamphetamine/ or
"ecstasy".mp OR MDMA".mp
#11 exp Psychedelic agent/ or hallucinogens.ab,ti or lsd.ab,ti
#12 exp *cocaine derivative/ or exp cocaine/
#13 exp *lysergic acid diethylamide/ or "lsd".mp
#14 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
#15 exp prevention and control/
#16 (peer adj group).ab,ti
#17 exp primary prevention/ or prevention.ab,ti
#18 exp education program
#19 exp health education/ or health education.mp.
#20 exp counseling/ or counseling.ab,ti
#21 exp health program
#22 exp daily life activity/
#23 exp social behavior/
#24 exp adolescent
#25 exp lifestyle/
#26 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or
25
#27 (4 or 14) and 26
PsycInfo (OVID - enero 1967 hasta febrero 2004):
#1 exp drug addiction
#2 (addict$ or abus$ or dependen$).ti,ab,sh.
#3 1 or 2
#4 exp narcotics/
#5 exp morphine/
#6 exp heroin
#7 cocaine.mp. or exp COCAINE/
#8 exp amphetamine/ or exp methylenedioxyamphetamine/
#9 ecstasy.ab,ti
#10 exp hallucinogenic drugs/
#11 exp psychedelic drugs/
#12 Lysergic Acid Diethylamide.mp. or exp Lysergic Acid
Diethylamide/ or LSD.ab,ti
#13 exp cannabis/ or cannabis.ab,ti
#14 exp marihuana/ or marijuana.ab,ti
#15 hashish.ti,ab.
#16 exp inhalant abuse/
#17 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or
15 or 16
#18 exp health education/ or health education.ab,ti
#19 exp prevention/
#20 exp counseling/ or counseling.ab,ti
#21 exp peer relations/ or (peer adj group).ab,ti
#22 exp social adjustment/
Pgina 5
#23 exp adolescent psychology/
#24 exp interpersonal interaction/
#25 18 or 19 or 20 or 21 or 22 or 23 or 24
#26 3 or 17
#27 26 and 25
ERIC (enero 1988 - febrero 2004)
Estrategia organizada con una enciclopedia, referida a las
sustancias de abuso y a las intervenciones.
SOCIOLOGICAL ABSTRACTS (1963-2000)
Bsqueda de sustancias de abuso e intervenciones: se utilizaron
trminos genricos ("DRUG ABUSE", "DRUG ADDICTION",
"DRUG DEPENDENCE") debido a que no pudieron utilizarse
los nombres especcos de sustancias.
Se incluyeron en el conjunto las editoriales, las revisiones, los
comentarios y las cartas al editor.
Se revisaron los artculos de revisin y todos los estudios
incluidos y excluidos citados para identicar otros estudios
signicativos.
Tambin se revisaron las editoriales, los comentarios y las cartas
pertinentes para identicar bibliografa til.
Se estableci contacto con otros equipos de investigacin y
revisin, y con 18 autores de los estudios incluidos, segn los
procedimientos sugeridos por la Colaboracin Cochrane
(Cochrane Collaboration), para identicar otros estudios
potencialmente pertinentes. Seis autores enviaron referencias
o artculos publicados y no publicados.
MTODOS DE LA REVI SI N
Para ser incluidos en esta revisin, los estudios se seleccionaron
en cuatro etapas:
(1) Los registros recuperados de cada base de datos se
almacenaron en una base de datos ProCite especca; los ttulos
se sometieron a un cribaje (screening) previo de su relevancia,
con la exclusin de los artculos no relacionados con el tema
en estudio, mediante expresiones o trminos de bsqueda
especcos.
(2) Dos revisores leyeron el resumen de cada estudio no
excluido en la etapa (1) para evaluar su relevancia y determinar
su exclusin si cumpla con uno o ms de los siguientes
criterios:
ausencia de foco claro en el consumo de marihuana o alguna
sustancia ilegal
. los participantes no eran alumnos de escuela primaria o
secundaria
no se trataba de un programa de prevencin primaria
. no era un ECA, un ECC, un EPC ni un estudio controlado
. presentacin de los resultados
En caso de desacuerdo, el estudio se inclua en el paso siguiente.
(3) Dos revisores obtuvieron y evaluaron de forma
independiente cada estudio no excluido en los pasos anteriores,
para incluirlo denitivamente.
(4) Dos revisores evaluaron la calidad interna de los estudios
incluidos segn la lista de control del CDAG (Amato 2005).
Se utiliz el sistema del CDAG para ponderar los criterios
utilizados en la evaluacin de los estudios. En los estudios
experimentales (ECA y ECC) se analizaron la asignacin al
azar, el ocultamiento de la misma, el cegamiento, las prdidas
durante el seguimiento y los criterios denidos como "otros",
p. ej. comparacin inicial de los grupos y ausencia de sesgo de
ejecucin; sobre la base del cumplimiento con estos criterios
se determin una puntuacin de calidad. Para los EPC, la
puntuacin de calidad se calcul a partir de la poblacin de
base, el ajuste para los factores de confusin, la inclusin de
todos los pacientes en el anlisis y otros criterios, como la
descripcin adecuada de la base y del tratamiento. Se identic
un umbral para la exclusin.
Finalmente, los estudios se dividieron en tres clases segn la
calidad:
A: bajo riesgo de sesgo (puntuaciones de nueve a 11 para ECA,
y de 11 a 13 para EPC)
B: riesgo de sesgo moderado (puntuaciones de seis a ocho para
ECA y de seis a diez para EPC)
C: alto riesgo de sesgo (puntuaciones de cero a cinco para ECA
y EPC)
Todos los desacuerdos se resolvieron mediante un tercer revisor.
Los resultados de la evaluacin de calidad se ilustran en las
Tablas adicionales: Tabla 01 para los ECA, y Tabla 02 para los
EPC.
Dos revisores extrajeron los datos de forma independiente
mediante una lista de control estandarizada. Los desacuerdos
se resolvieron mediante un tercer revisor.
El estudio de Botvin 1990 present anlisis de un grupo de alta
delidad, que incluy los estudiantes del grupo de intervencin
que participaron en al menos un 60% del programa, pero slo
se extrajeron los datos de la poblacin total de este estudio.
Se estableci contacto por correo electrnico con 14 autores
para solicitarles informacin complementaria y la referencia se
incluy en la seccin "En espera de evaluacin". Ocho de los
mismos respondieron, y tres proporcionaron los datos solicitados
que permitieron la integracin en el anlisis. En los casos en
que no respondieron despus de seis meses del envo de las
solicitudes de datos, dos revisores volvieron a evaluar los
estudios para su inclusin o exclusin.
Segn el contenido del programa, se clasicaron los brazos de
intervencin y de control en los siguientes grupos:
aquellos que se centraron en las habilidades, dirigidos a
aumentar la capacidad de los estudiantes en las habilidades
genricas, de rechazo y de seguridad
Pgina 6
aquellos centrados en la respuesta afectiva, dirigidos a
modicar las cualidades internas (rasgos de personalidad
como la autoestima y la ecacia individual, y aspectos de
la motivacin como la intencin de consumir drogas)
programas centrados en el conocimiento, dirigidos a
aumentar el conocimiento sobre las drogas, los efectos y
consecuencias de las mismas
currculo habitual.
Las intervenciones tambin se clasicaron segn la modalidad
de enseanza, con base a lo declarado en los artculos:
programas interactivos, en los cuales los participantes
intervienen activamente en las actividades organizadas y
experimentan los conocimientos, las habilidades o los aspectos
afectivos que estn aprendiendo. Se incluyen la representacin
de roles, la discusin grupal, la participacin del compaero
lder, etc.
programas pasivos, que consisten en lecciones convencionales,
en las cuales la comunicacin es principalmente unidireccional
del profesor o educador a los nios.
Finalmente, los estudios se clasicaron segn las personas que
participaron en su administracin:
profesores
educadores externos
compaeros
Los resultados de las clasicaciones se informaron en la Tabla
03.
Los datos se analizaron con el programa Revman. Los ECA,
ECC y EPC se analizaron por separado.
Se calcul el tamao del efecto estandarizado para cada estudio,
en base a los resultados informados. Cuando fue posible, se
calcul el riesgo relativo y el intervalo de conanza del 95%,
mediante un modelo de efectos aleatorios (Deeks 2001); para
los resultados continuos se calcul la diferencia de medias
estandarizada (DME) entre los grupos para resumir los
resultados entre los estudios donde se midieron de diferentes
maneras. Se realiz una prueba para evaluar la heterogeneidad
estadstica. El efecto de la misma se veric cuando dos o ms
estudios se incluan en el metanlisis.
Para el estudio de Furr-Holden 2004, que requiri el ajuste para
el efecto del agrupamiento para los factores de confusin, se
retuvo el nmero absoluto de sujetos en el numerador de la
medida de riesgo del grupo control; por el contrario, los
"nmeros ajustados" de sujetos en el grupo de tratamiento se
volvieron a calcular para cada resultado como el producto de
los RR ajustados por el nmero absoluto en el grupo control.
Algunos ECA (Bernstein 1987; Botvin 1984; Botvin 1990;
Botvin 1997; Clayton 1991; Cook 1984; Ellickson 1990; Hansen
1988; Malvin 1985; Moskowitz 1984; Rosenbaum 1994; Ross
1998; Sexter 1984) presentaron datos inadecuados para la
inclusin en el metanlisis. Los resultados de estos estudios se
resumieron en las Tablas adicionales (Tabla 04; Tabla 05).
Los resultados de todos los EPC incluidos se resumieron en la
Tabla adicional 06.
Para los estudios que proporcionaron datos inadecuados para
la inclusin en las tablas del metanlisis, se generaron otras
tablas adicionales (Tabla 07; Tabla 08; Tabla 09) para sintetizar
los resultados, cuando se evaluaron al menos en dos estudios.
Para evaluar el efecto de los estudios de baja calidad sobre los
resultados en conjunto, se realizaron anlisis de sensibilidad
con los estudios que proporcionaron datos para los metanlisis
con la inclusin o la exclusin de aquellos de clase C.
No se realiz ninguna evaluacin del sesgo de publicacin.
Los resultados del metanlisis se integraron en una discusin
que consider otras publicaciones pertinentes . La convergencia
entre los resultados del metanlisis y la revisin narrativa se
consider un indicador de evidencia slida del efecto.
DESCRI PCI N DE LOS ESTUDI OS
Las tablas ilustran las caractersticas de los estudios excluidos
e incluidos.
ESTUDIOS EXCLUIDOS
Se excluyeron 50 estudios (62 informes).
Diecinueve estudios eran ECA, de los cuales seis (Ambtman
1990; Bry 1982; Rollin1994; Kim 1993; LoSciuto 1988; Shope
1996; Villalb 1993) se excluyeron debido a fracaso del proceso
de asignacin al azar. Dos estudios realizados por Botvin y cols.
(Botvin 2000a y Grifn 2003) y el realizado por Snow (Snow
1997) presentaron un anlisis secundario de submuestras de los
ensayos originales (Botvin 1990, Snow 1992, Botvin 2001), ya
incluidos en la revisin. En los estudios de Graham 1990 y
Eggert 1994 se combinaron tres cohortes consecutivas de
estudiantes para el anlisis, pero los programas fueron
diferentes. En el estudio de Donaldson (Donaldson 1994) la
asignacin al azar inicial a los grupos no se consider en el
anlisis, mientras que el estudio de Olton (Olton 1985) no
present los datos acerca del grupo control. En dos estudios
(Dent 1998; Calafat 1984) el procedimiento de asignacin al
azar fue incierto. En el estudio de De La Rosa 1995 las unidades
de asignacin al azar fueron muy limitadas como para asegurar
la validez del mtodo. En el estudio de O'Donnell (O'Donnell
1995) el procedimiento de asignacin al azar se aplic slo a
una submuestra del estudio. En el estudio de Short (Short 1998)
los sujetos asignados a los grupos de intervencin y de control
fueron submuestras de diferentes grupos de poblacin. El
estudio de Duncan 2000 no present los criterios para
seleccionar a los estudiantes. En el estudio de Schinke 2000 los
estudiantes incluidos eran indgenas americanos, y la
intervencin se centr en su cultura y sus tradiciones.
Todos los otros estudios excluidos (n = 31) fueron EPC; los
mismos se excluyeron principalmente debido al control
inadecuado de las variables de confusin, excepto por el estudio
de Freimuth (Freimuth 1997) que compar los resultados de
Pgina 7
los grupos de intervencin y de control con evaluaciones previas
combinadas, y por el estudio de Skroban (Skroban 1999) que
analiz una poblacin con un seguimiento de cinco aos
diferente a la poblacin de estudio original. En tres estudios la
relacin individual entre los resultados previos y posteriores a
la intervencin fue incierta (Becker 1992; Dedobbeleer 2001;
Kim 1982). El estudio de Midwestern (Pentz 1989), que incluy
seis artculos por diferentes autores, fue un ensayo de mltiples
comunidades: el mismo se excluy debido a que no fue posible
separar el efecto de la intervencin escolar del efecto del
programa comunitario. De forma similar, el estudio Early
Alliance (Prinz 2000) compar la intervencin escolar con una
intervencin en mltiples contextos, que inclua la comunidad
y las familias. El estudio de DeWit 2000 no present los
criterios para seleccionar los estudiantes con alto riesgo.
ESTUDIOS INCLUIDOS
En total se incluyeron 32 estudios a partir de 46 informes.
Diseo de los estudios
Veintinueve estudios eran ECA y tres eran EPC; diecisiete de
los mismos (14 ECA y tres EPC) no presentaron datos tiles
para incluir en los metanlisis, debido al modelo estadstico
utilizado en el anlisis y, algunas veces, debido a la baja calidad
de la informacin. Sin embargo, estos estudios proporcionaron
resultados adecuados para la presentacin narrativa y se
incluyen en las Tablas adicionales (Tabla 04 y Tabla 05 para
los ECA; Tabla 06 para los EPC).
Grado de los estudiantes en el momento de la intervencin
- 1: 1 ECA
- 3: 4 ECA
- 6: 3 ECA
- 6: 5 ECA
- 7: 13 ECA, un EPC
- 6: 2 ECA
- 6: 4 ECA
- 10: 1 ECA
- 11: 1 ECA
- escuela secundaria (grado no especicado): cuatro ECA, un
EPC
- escuela primaria (grado no especicado): un ECA, un EPC
Duracin del seguimiento
- inmediatamente despus de la intervencin: 18 ECA, un EPC
- 1 ao: 13 ECA, dos EPC
- 2 aos: seis ECA, un EPC
- 3 aos: un ECA, un EPC
- 5 aos: 3 ECA
- 6 aos: dos ECA, un EPC
- 7 aos: 1ECA
- 10 aos: 1 ECA
mbito
- EE.UU.: 28 ECA, dos EPC
- Canad: un EPC
- RU: 1 ECA
Programas de intervencin
- DARE (Drug Abuse [Abuso de Drogas]): dos ECA, un EPC
- Life Skills Training Program (Programa de entrenamiento de
las habilidades de la vida cotidiana): 3 ECA
- Rehearsal Plus Program (Programa ms ensayo): 3 ECA
- ALERT: 2 ECA
- SMART (Self management and Resistance Training
[Autocontrol y entrenamiento de resistencia]): 1 ECA
- CHARLIE (Chemical Abuse Resolution Lies in Education
[Resolucin del abuso de sustancias qumicas basada en la
educacin]): 1 ECA
- WHOA, A Great Way to Say No (Una excelente manera de
decir no): 1 ECA
- PAY (Positive Alternatives for Youth [Alternativas positivas
para la juventud]): 1 ECA
- NAPA Project (Proyecto NAPA): 1 ECA
- PAVOT (Promotion de l'Autonomie et de la Volont de faire
Obstacle aux Toxicomanies [Promocin de la autonoma y la
voluntad de accin como obstculo de la toxicomana]): un
EPC
- TND (Project Towards No Drug abuse [Proyecto a favor del
no abuso de drogas]): 3 ECA
- KACM (Keep A Clear Mind Program [Programa para
mantener la mente despejada]): 1 ECA
- Urban Youth Connection Program (Programa de conexin
con la juventud urbana): un EPC
- Cognitive Behavioral Skills Intervention (Intervencin de las
habilidades cognitivo-conductuales): 1 ECA
- Cross Age Tutoring (Tutora entre edades cruzadas): 1 ECA
- Drug Abuse Prevention Curriculum (Programa de prevencin
del abuso de drogas): 1 ECA
- ASAP (Alcohol and Substance Abuse Prevention Program
[Programa de prevencin del abuso de alcohol y sustancias]):
1 ECA
- AAPT (Adolescent Alcohol Prevention Trial [Ensayo de
prevencin del alcoholismo en adolescentes]): 1 ECA
- DRSP (Drug resistance Strategies Project [Proyecto de
estrategias para la resistencia a las drogas]): 1 ECA
- No se proporcion ningn nombre: 4 ECA
Principales objetivos educativos
- habilidades: 25 ECA, dos EPC
- respuesta afectiva: seis ECA, un EPC
- conocimiento: 6 ECA
Tcnica educativa
- interactiva: 27 ECA, dos EPC
- pasiva: 6 ECA
- asesoramiento: Un EPC
Administradores
- educadores externos: 20 ECA, un EPC
- profesores: diez ECA, un EPC
- compaeros lderes: 4 ECA
- otros (polica): dos ECA, un EPC
Sesiones de apoyo
Pgina 8
-s: 5 ECA
- no: 24 ECA, tres EPC
Activacin del contexto
- alta: 3 ECA
- baja: 26 ECA, tres EPC
Comparaciones
Diecisis estudios (Bernstein 1987; Botvin 1997; Botvin 2001;
Clayton 1991; Cook 1984; Snow 1992; Hurry 1997; Kim 1989;
Moskowitz 1984; Ringwalt 1991; Ross 1998; Rosenbaum 1994;
Valentine 1998; Werch 1991; Dent 2001; Ellickson 2003)
tuvieron dos brazos que compararon un grupo de tratamiento
con un grupo de control, de "ninguna intervencin" (programa
habitual). Nueve estudios tuvieron tres brazos (Botvin 1990;
Botvin 1994; Corbin 1993; Ellickson 1990; Hansen 1988; Jones
1990; Jones 1995; Sussman 1998; Sussman 2002; Furr-Holden
2004), que compararon dos grupos de intervencin y un grupo
de control, este ltimo con el currculo habitual. Un estudio
(Malvin 1985) compar dos grupos de intervencin con dos
grupos de control, un estudio (Sigelman 2003) compar tres
grupos de intervencin con un grupo de control, dos estudios
(Botvin 1984; Hecht 1993) compararon cuatro grupos de
intervencin con un grupo de control y un estudio (Sexter 1984)
compar cinco grupos de intervencin con un grupo de control.
Un estudio, Hansen 1991, compar cuatro intervenciones entre
s.
Se realizaron ocho comparaciones:
- Comparacin 1: conocimiento versus currculo habitual (cuatro
ECA)
- Comparacin 2: respuesta afectiva versus currculo habitual
(cinco ECA y un EPC)
- Comparacin 3: habilidades versus currculo habitual (20 ECA
y dos EPC)
- Comparacin 4: habilidades versus conocimiento (cuatro ECA)
- Comparacin 5: respuesta afectiva versus conocimiento (cuatro
ECA)
- Comparacin 6: habilidades versus respuesta afectiva (tres
ECA)
- Comparacin 7: tcnica interactiva versus pasiva (cuatro ECA)
- Comparacin 8: compaeros versus educadores externos (un
ECA)
Los detalles sobre los grupos de comparacin se muestran en
las tablas de "Caractersticas de los estudios incluidos".
Medidas de resultado
Se mostraron los datos sobre varios resultados de inters:
conocimiento sobre las drogas: 12 ECA y un EPC
autoestima: seis ECA y dos EPC
ecacia individual: cinco ECA y un EPC
locus de control: 1 ECA
ansiedad social: 2 ECA
resistencia / susceptibilidad a la presin de los compaeros:
tres ECA y un EPC
seguridad en s mismo: cinco ECA y un EPC
habilidades para la toma de decisiones: 7 ECA
consumo de drogas en adultos: 3 ECA
consumo de drogas en compaeros: 8 ECA
actitudes hacia las drogas: diez ECA y un EPC
intencin de consumir drogas: 5 ECA
consumo de marihuana: 17 ECA y dos EPC
consumo de inhalantes: 3 ECA
consumo de drogas: nueve ECA y un EPC
consumo de drogas duras: 6 ECA
CALI DAD METODOLGI CA
ECA
Todos los ECA mencionaron que el procedimiento de
asignacin fue al azar, sin ninguna descripcin adicional.
Ningn estudio describi los procedimientos de ocultamiento
de la asignacin con suciente detalle como para ilustrar su
adecuacin.
Ninguno de los 29 ECA adopt estrategias de cegamiento; aun
as, es posible excluir razonablemente el sesgo de informacin
debido a la naturaleza del contexto y a que los datos de los
resultados se obtuvieron en general mediante un cuestionario
autoadministrado.
En dieciocho estudios, (Bernstein 1987; Botvin 1984; Botvin
1994; Botvin 1997; Cook 1984; Corbin 1993; Snow 1992; Hurry
1997; Jones 1990; Moskowitz 1984; Ringwalt 1991; Sussman
1998; Werch 1991; Ellickson 2003; Sigelman 2003;
Furr-Holden 2004; Hansen 1991; Jones 1995) las prdidas
durante el seguimiento fueron inferiores al 25%, mientras que
en ocho estudios (Botvin 1990; Botvin 2001;Clayton 1991;
Ellickson 1990 ; Hansen 1988; Malvin 1985; Dent 2001;
Sussman 2002) oscilaron entre el 25% y el 45%; en tres (Kim
1989; Sexter 1984; Hecht 1993) estudios la desercin no se
describi adecuadamente.
En general, las caractersticas de los estudiantes y los criterios
de inclusin y exclusin se denieron de manera adecuada. La
similitud entre los grupos de estudio al comienzo de los ensayos
fue, en general, buena excepto por seis estudios en los que la
misma fue incierta (Bernstein 1987; Cook 1984; Kim 1989;
Malvin 1985; Sexter 1984; Ellickson 2003; Hecht 1993) y cinco
estudios en los cuales los grupos no fueron similares
(Furr-Holden 2004; Hansen 1988; Ringwalt 1991; Moskowitz
1984; Hansen 1991).
En todos los estudios, los estudiantes en los diferentes brazos
fueron tratados del mismo modo, independientemente de la
intervencin en estudio.
El nmero de estudiantes incluidos fue generalmente bastante
alto y oscil desde menos de 100 (Bernstein 1987; Corbin 1993;
Jones 1990; Malvin 1985; Jones 1995) hasta 6527 sujetos
(Ellickson 1990).
Pgina 9
Segn estos criterios, veintitrs estudios se consideraron
(Bernstein 1987; Botvin 1984; Botvin 1990; Botvin 1994;
Botvin 1997; Botvin 2001; Clayton 1991; Cook 1984; Corbin
1993; Dent 2001; Ellickson 1990; Furr-Holden 2004; Snow
1992; Hurry 1997; Jones 1990; Jones 1995; Moskowitz 1984;
Ringwalt 1991; Sussman 1998; Werch 1991; Ellickson 2003;
Sigelman 2003; Hansen 1991) de calidad moderada (clase B)
y seis (Hansen 1988; Kim 1989; Malvin 1985; Sexter 1984;
Hecht 1993; Sussman 2002) de baja calidad (clase C).
Adems de evaluar la calidad mediante la lista de control
proporcionada por el Grupo Cochrane de Drogas y Alcohol
(Ferri 2003), tambin se investig el efecto del agrupamiento
(Campbell 2001). Slo seis estudios (Dent 2001; Sussman 2002;
Ellickson 2003; Furr-Holden 2004; Botvin 2001) consideraron
este efecto en su diseo y anlisis.
EPC
Slo uno (Rosenbaum 1994) de los tres EPC incluidos en esta
revisin proporcion una descripcin adecuada de la poblacin
de base y de los criterios de inclusin y exclusin (Ross 1998;
Valentine 1998).
El nmero de participantes oscil entre 491 (Ross 1998) y 1800
(Rosenbaum 1994).
Las prdidas durante el seguimiento fueron menores al 25% en
un estudio (Rosenbaum 1994), menores al 40% en el segundo
(Ross 1998) y mayores al 40% en el tercero (Valentine 1998).
El ajuste para las variables de confusin fue adecuado en un
estudio (Ross 1998) y parcialmente adecuado en los otros dos
(Rosenbaum 1994; Valentine 1998).
Los tres estudios proporcionaron una descripcin adecuada de
las caractersticas de base de los grupos comparados. La
descripcin de los tratamientos concomitantes fue inadecuada
en un estudio (Valentine 1998).
Segn estos criterios, un estudio se consider (Ross 1998) de
alta calidad (clase A), uno (Rosenbaum 1994) de calidad
moderada (clase B) y uno (Valentine 1998) de baja calidad
(clase C).
RESULTADOS
Los resultados, tanto de los ECA como de los EPC, se presentan
en grcos cuando proporcionaron datos para el metanlisis, y
en las Tablas adicionales en los otros casos (Tabla 04, Tabla
05 para los ECA y Tabla 06 para los EPC).
A los nes del anlisis de sensibilidad, los estudios de clase C
se especican en el texto.
Los efectos de las intervenciones sobre la seguridad en s
mismo, las actitudes hacia las drogas y la intencin de consumir
drogas no fueron estadsticamente signicativos en ninguna de
las comparaciones. Los resultados correspondientes se incluyen
en los grcos pero no se describen adicionalmente en el texto.
Resultados de los ECA
Conocimiento versus currculo habitual
Tres estudios incluyeron un brazo basado en el conocimiento
sobre las drogas (Corbin 1993; Jones 1995; Sigelman 2003).
Sus resultados mostraron que el conocimiento sobre las drogas
aument despus de la intervencin (DME = 0,91; IC del 95%:
0,42; 1,39 - prueba de heterogeneidad p = 0,17) cuando se
compar con el grupo de control con el currculo habitual, pero
las habilidades para la toma de decisiones no aumentaron (DME
= -0,06; IC del 95%: -0,60; 0,47 - prueba de heterogeneidad p
= 0,34). En el estudio de Sexter 1984, de calidad C, tambin se
evalu un brazo de conocimiento (los resultados se presentan
en la Tabla 05), pero no mostr ningn efecto signicativo en
la comparacin del consumo de drogas antes y despus de la
intervencin.
Habilidades versus currculo habitual
La intervencin basada en las habilidades aument
signicativamente el conocimiento sobre las drogas despus
de la misma, cuando se compar con el currculo habitual (DMP
= 2,60; IC del 95%: 1,17; 4,03) (Hurry 1997). Este resultado
se conrma en el estudio realizado por Botvin 1984, que
muestra un aumento del conocimiento sobre la marihuana en
todos los brazos, en comparacin con los controles, despus de
la intervencin; lo mismo ocurre en el brazo de compaeros
con apoyo al ao de seguimiento, en el estudio realizado por
Moskowitz 1984, que muestra un aumento del conocimiento
en el grupo de hombres en el brazo de intervencin al ao de
seguimiento y por Botvin 1990 a los tres aos de seguimiento.
Sin embargo, los estudios realizados por Malvin 1985, de
calidad C, y por Moskowitz 1984 no mostraron ninguna
diferencia signicativa en el conocimiento sobre las drogas
despus de la intervencin y al ao de seguimiento (Malvin
1985, de calidad C). Otro estudio de calidad C, Werch 1991,
no mostr diferencias en el conocimiento sobre la marihuana
despus de la intervencin.
Las intervenciones sobre las habilidades fueron superiores para
mejorar las habilidades para la toma de decisiones (DME =
0,78; IC del 95%: 0,46; 1,09 - prueba de heterogeneidad p =
0,09) (Snow 1992; Hurry 1997), excepto para Botvin 1997
despus de la intervencin y para Botvin 1990 a los tres aos
de seguimiento; tambin mejoraron la resistencia a la presin
de los compaeros (RR = 2,05; IC del 95%: 1,24; 3,42) (Hurry
1997), y aumentaron ligeramente la autoestima (DME = 0,22;
IC del 95%: 0,03; 0,40 - prueba de heterogeneidad p = 0,32)
(Hurry 1997; Kim 1989 Clasicacin de calidad: C), en
comparacin con el currculo habitual despus de la
intervencin. El efecto sobre la resistencia a la presin de los
compaeros se conrma en el estudio de Clayton 1991, al ao
de seguimiento; sin embargo, en este estudio, la autoestima fue
ms baja en el grupo de intervencin a los diez aos de
seguimiento. La autoestima aument signicativamente en el
brazo de intervencin en el estudio de Cook 1984 al ao de
seguimiento, y a los tres aos de seguimiento en el estudio de
Botvin 1990.
Pgina 10
El consumo de drogas genricas (RR = 0,81; IC del 95%: 0,64;
1,02 - prueba de heterogeneidad p = 0,30) (Snow 1992;
Ringwalt 1991) y el consumo de drogas duras, tanto como
resultado continuo (DME = -0,30; IC del 95%: -0,85; 0,25 -
prueba de heterogeneidad p < 0,0001) (Snow 1992; Sussman
1998) como resultado dicotmico (RR = 0,45; IC del 95%:
0,24; 0,85 - prueba de heterogeneidad p = 0,55), se vieron
afectados positivamente por las intervenciones sobre las
habilidades, en comparacin con el currculo habitual en
Sussman 2002 (de calidad C), a los dos aos de seguimiento y
en Furr-Holden 2004, a los cinco aos de seguimiento. Este
resultado se conrma en Botvin 1997 y en Hecht 1993 (de
calidad C) despus de la intervencin, y tambin en Dent 2001
al ao de seguimiento. Por el contrario, el consumo de drogas
genricas no mostr diferencias al ao en el estudio de Cook
1984 y a los diez aos en el estudio de Clayton 1991.
La intervencin basada en las habilidades no mostr ningn
efecto sobre el consumo de marihuana como resultado continuo
(DME = -0,05; IC del 95%: -0,10; 0,01 - prueba de
heterogeneidad p = 0,38), (Snow 1992; Sussman 1998; Botvin
2001), lo que fue conrmado por Dent 2001, Clayton 1991 al
ao y a los diez aos, y por Cook 1984 al ao de seguimiento.
Sin embargo, Botvin 1984, Botvin 1997, Sexter 1984 (de calidad
C) y Hecht 1993 (de calidad C) mostraron un efecto positivo
en el brazo basado en las habilidades despus de la intervencin.
Botvin 1984 mostr un efecto signicativo de la intervencin
sobre el consumo de marihuana al ao de seguimiento, y
tambin lo hizo el metanlisis de cuatro estudios (RR = 0,82;
IC del 95%: 0,73; 0,92 - prueba de heterogeneidad p = 0,37):
Ellickson 2003 al ao de seguimiento, Sussman 2002 (de calidad
C) a los dos aos, Furr-Holden 2004 a los cinco aos y Botvin
1990 a los seis aos de seguimiento. A los nes del anlisis de
sensibilidad, la exclusin del estudio de calidad C de este
metanlisis no modic el resultado: RR = 0,81; IC del 95%:
0,72; 0,91 - prueba de heterogeneidad p = 0,25. Botvin 1990
mostr un efecto signicativo a los tres aos de seguimiento.
Ellickson 1990 no mostr diferencias signicativas en el
consumo de marihuana a los dos, tres y cinco aos.
Sexter 1984 (de calidad C) detect un efecto positivo sobre el
consumo de pegamentos; sin embargo, Botvin 2001 no encontr
ningn efecto sobre el consumo de inhalantes, como resultado
continuo, al ao de seguimiento (DMP = -0,05; IC del 95%:
-0,11; 0,01) y Furr-Holden 2004 no encontr ningn efecto
sobre el resultado dicotmico (RR = 1,00; IC del 95%: 0,60;
1,66) a los cinco aos de seguimiento.
Respuesta afectiva versus currculo habitual
En dos estudios, el conocimiento sobre las drogas aument
signicativamente en el brazo de intervencin afectiva, despus
de la misma, en comparacin con el brazo del currculo habitual
(Corbin 1993; Jones 1995) (DME: 1,88, IC del 95%: 1,27; 2,59;
- prueba de heterogeneidad p = 0,36). En estos estudios, las
habilidades para la toma de decisiones tambin mejoraron
signicativamente con la intervencin (DME: 1,35; IC del 95%:
0,79; 1,91 - prueba de heterogeneidad p = 0,82). No se inform
ninguna diferencia signicativa en el conocimiento y en la
conducta autoinformada en el estudio de Bernstein 1987,
mientras que en el de Hansen 1988 (de calidad C) el grupo de
la intervencin afectiva consumi signicativamente ms
marihuana al ao (p = 0,004) y a los dos aos (p = 0,0003) de
seguimiento comparado con los controles. En el estudio de
Sexter 1984, de calidad C, el consumo de drogas psicodlicas
y estimulantes despus de la intervencin fue menor en el brazo
de la respuesta afectiva.
Habilidades versus conocimiento
Lo programas basados en el refuerzo de las habilidades,
comparados con aquellos basados en el conocimiento, mostraron
un efecto pequeo sobre el conocimiento de las drogas despus
de la intervencin (DME = 0,02; IC del 95%: -0,18; 0,22 -
prueba de heterogeneidad p = 0,50) (Botvin 1994; Jones 1990).
Las habilidades para la toma de decisiones tampoco se vieron
inuenciadas por las intervenciones basadas en las habilidades,
despus de las mismas, en comparacin con las intervenciones
basadas en el conocimiento (DMP = -0,75; IC del 95%: -5,61;
4,11) (Botvin 1994). No hubo ninguna diferencia evidente entre
las intervenciones en cuanto al aumento de la ecacia individual
(DME = 0,13; IC del 95%: -0,37; 0,63 - prueba de
heterogeneidad p = 0,16) (Botvin 1994; Jones 1990), y la
autoestima (DMP = -0,31; IC del 95%: -3,92; 3,30) (Botvin
1994), despus de la intervencin. A los dos aos de
seguimiento, Botvin 1994 encontr un efecto signicativo sobre
el conocimiento sobre la marihuana a favor del grupo control
con informacin solamente.
Un estudio, Hansen 1991, evalu la diferencia en el consumo
de marihuana entre dos programas basados en las habilidades
y uno basado en el conocimiento: uno de los dos programas
basados en las habilidades (educacin normativa) redujo el
consumo de marihuana al ao de seguimiento pero no a los dos
aos de seguimiento, mientras que el otro (entrenamiento de
resistencia) no fue efectivo sobre dicho consumo al ao y a los
dos aos de seguimiento.
Respuesta afectiva versus conocimiento
En comparacin con las intervenciones basadas en el
conocimiento, aquellas centradas en la respuesta afectiva
aumentaron ligeramente el conocimiento sobre las drogas (DME
= 0,60; IC del 95%: 0,18; 1,03 - prueba de heterogeneidad p =
0,94) (Jones 1990; Jones 1995; Corbin 1993). Se observ un
mayor efecto sobre las habilidades para la toma de decisiones
(DME = 1,22; IC del 95%: 0,33; 2,12 - prueba de
heterogeneidad p = 0,11) (Corbin 1993; Jones 1995), mientras
que la ecacia individual no se vio afectada (DMP = -1,00; IC
del 95%: -2,94; 0,94) despus de la intervencin en el estudio
de Jones 1990.
Habilidades versus respuesta afectiva
Jones 1990 mostr que las intervenciones basadas en las
habilidades fueron mejores que aquellas basadas en la respuesta
afectiva para aumentar la ecacia individual (DMP = 1,90; IC
del 95%: 0,25; 3,55), pero no el conocimiento sobre las drogas
Pgina 11
despus de la intervencin (DMP = -0,60; IC del 95%: -1,48;
0,28).
Tcnicas interactivas versus pasivas
Se compararon los estudios en los cuales se utilizaron tcnicas
interactivas versus pasivas, independientemente de su tipo.
Solamente tres estudios (Botvin 1994; Jones 1990; Sussman
2002) proporcionaron datos adecuados para el metanlisis: los
resultados no fueron estadsticamente signicativos con respecto
al conocimiento sobre las drogas (DME = 0,02; IC del 95%:
-0,18; 0,22 -prueba de heterogeneidad p = 0,50), (Botvin 1994;
Jones 1990), las habilidades para la toma de decisiones (DMP
= -0,75; IC del 95%: -5,61; 4,11), (Botvin 1994), la autoestima
(DMP = -0,31; IC del 95%: -3,92; 3,30), (Botvin 1994), la
ecacia individual (DME = 0,13; IC del 95%: -0,37; 0,63 -
prueba de heterogeneidad p = 0,16) (Botvin 1994; Jones 1990),
y el consumo de marihuana (RR = 0,78; IC del 95%: 0,49; 1,23).
Sin embargo, las tcnicas interactivas fueron ms efectivas para
reducir el consumo de drogas duras en el estudio de Sussman
2002 (RR = 0,43; IC del 95%: 0,19 a 0,99).
Rol de los compaeros
Los programas fueron signicativamente ms efectivos con
respecto al conocimiento sobre la marihuana y las actitudes
hacia la misma despus de la intervencin y, para el locus de
control, cuando fueron administrados por compaeros versus
profesores (Botvin 1984; Botvin 1990). Las actitudes hacia la
marihuana al ao de seguimiento fueron menores en el grupo
dirigido por profesores, (Botvin 1984; Botvin 1990) y los
ndices de su consumo fueron signicativamente inferiores en
el grupo dirigido por compaeros tanto despus de la
intervencin como al ao de seguimiento (Botvin 1984; Botvin
1990).
En comparacin con los educadores externos, el efecto de los
compaeros result evidente para el conocimiento sobre las
drogas (DMP = -3,42; IC del 95%: -6,81; -0,03) (Botvin 1994),
pero no fue signicativo para los otros resultados: habilidades
para la toma de decisiones (DMP = 1,94; IC del 95%: -2,12;
6,00) (Botvin 1994), autoestima (DMP = 1,69; IC del 95%:
-1,33; 4,71) (Botvin 1994), ecacia individual (DMP = 3,57;
IC del 95%: -0,87; 8,01) (Botvin 1994).
Resultados de los EPC
En general, estos estudios no lograron producir resultados
estadsticamente signicativos.
Habilidades versus currculo habitual
En el estudio de Rosenbaum 1994, las actitudes hacia las drogas,
la autoestima y la resistencia a la presin de los compaeros se
evaluaron despus de la intervencin , al ao, a los dos y a los
seis aos posteriores al programa. Solamente se obtuvo un
resultado signicativo para la autoestima despus de la
intervencin. En el estudio de Ross 1998 no se obtuvo ningn
resultado signicativo. Tampoco se encontr una diferencia
signicativa en el consumo de marihuana en el estudio de
Rosenbaum 1994.
Respuesta afectiva versus currculo habitual
En el estudio de Valentine 1998, de calidad C, el consumo de
marihuana y la autoestima favorecieron al grupo con el currculo
habitual, al ao y a los tres aos de seguimiento, para la muestra
de escuela secundaria; por otra parte, en la muestra de escuela
intermedia, la autoestima aument en el grupo de intervencin
y el consumo de marihuana fue indiferente.
DI SCUSI N
En esta revisin, los tres grupos de programas de prevencin,
basados en el conocimiento, las habilidades y la respuesta
afectiva, mostraron diferentes patrones de ecacia con respecto
a resultados individuales:
los programas basados en el conocimiento mejoran las
variables de intervencin [CD1](especialmente el
conocimiento sobre las drogas) en comparacin con el
currculo habitual, pero no son ms efectivos que los
programas basados en las habilidades. Cuando se
consideran los resultados nales, es decir, el consumo de
drogas, sus efectos son comparables a aquellos del
currculo habitual y de los otros dos tipos de programas;
los programas basados en la respuesta afectiva mejoran
las habilidades para la toma de decisiones y el
conocimiento sobre las drogas en comparacin con el
currculo habitual y las intervenciones basadas en el
conocimiento. Dos estudios, de baja calidad,
proporcionaron resultados conictivos: Sexter 1984 mostr
un efecto positivo sobre el consumo de drogas, mientras
que Hansen 1988 mostr el efecto opuesto sobre la
marihuana. Este resultado coincide con el un EPC de baja
calidad con estudiantes de escuela secundaria, que sugiere
un aumento del consumo de marihuana despus de la
intervencin afectiva, en comparacin con el currculo
habitual (Valentine 1998a).
los programas basados en las habilidades tienen un efecto
positivo sobre las variables de intervencin (conocimiento
sobre las drogas, toma de decisiones, autoestima y
resistencia a la presin de los compaeros) y sobre los
resultados nales, en comparacin con el currculo
habitual. El metanlisis de las variables dicotmicas sobre
el consumo de drogas en general, drogas duras y
marihuana muestra que este es menor en los grupos de
intervencin despus de la misma, aun aos despus de
dicha intervencin; la mayora de los ECA incluidos son
de calidad metodolgica satisfactoria, principalmente con
calicacin de calidad B. Por otro lado, la nica diferencia
derivada de la comparacin de los programas basados en
las habilidades con otra clase de intervenciones, se
relaciona con el aumento de la autoestima.
Los hallazgos presentan algunas limitaciones:
ninguno de los ECA cumpli con todos los criterios de
calidad utilizados en esta revisin, ya que todos se
Pgina 12
clasicaron como B o C. An as, todos, excepto uno, de
los estudios incluidos en los metanlisis tuvieron una
puntuacin de calidad B;
muchas comparaciones entre las intervenciones nunca se
estudiaron: por ejemplo, no se encontraron comparaciones
entre las intervenciones afectivas con otras con respecto
al comportamiento hacia las drogas.
la mayora de los resultados son posteriores a la
intervencin y existe poca evidencia de seguimientos a
largo plazo;
muchos ECA no presentan medidas de efecto sino slo
indicadores estadsticos (f, p...) u otras medidas de efecto
heterogneas, por lo que no fue posible combinarlos en el
metanlisis;
el control de heterogeneidad no es satisfactorio. Algunas
fuentes de heterogeneidad se controlaron mediante el
diseo de la revisin (resultado, mtodos de intervencin,
diseo y calidad de los estudios), pero muchas otras
fuentes de heterogeneidad "clnica", como el grado de
escolaridad, la intensidad de la intervencin o la duracin
del seguimiento, no pueden considerarse. No hay
sucientes ensayos en los estratos de cada variable elegible
como para permitir una metarregresin (Sterne 2001). En
estas condiciones, no es posible corregir la heterogeneidad
cuando un metanlisis utiliza resultados a nivel de los
ensayos. Podra generarse informacin sin sesgos mediante
el uso en el anlisis de las caractersticas a nivel individual,
con acceso a los datos originales, pero esto no es un
enfoque realista. La mayora de los autores con los que se
estableci contacto para que proporcionen datos
complementarios respondi que no podan hacerlo porque
el conjunto de datos ya no estaba disponible;
slo cuatro de los 29 ECA incluidos se disearon para
controlar el efecto del agrupamiento, como se discutir a
continuacin.
Otra limitacin es que los estudios no incluyeron algunas
estructuras complejas que tienen un papel reconocido en la
determinacin del consumo de drogas en adolescentes. Los
compaeros, la familia y el contexto social estn relacionados
fuertemente con el proceso causal del consumo de drogas en
los jvenes (Hawkins 1992; Hawkins 2002). El objetivo de esta
revisin es el papel de los programas de intervencin en el
mbito escolar; el modelo aleatorio de evaluacin permite que
sus efectos se evalen por separado de otros determinantes del
consumo de drogas. Sera interesante estudiar la interaccin
entre las caractersticas del contexto y la repercusin de los
programas, pero la misma no se contempl en esta revisin.
A pesar de estos lmites, la revisin produjo un patrn
consistente de resultados: los programas basados en las
habilidades de la vida cotidiana son los ms efectivos para
reducir el consumo de drogas. Estos programas tienen como
objetivo los factores de riesgo y de proteccin a nivel individual
asociados con el consumo de drogas en adolescentes; se basan
en el concepto de que los factores sociales y psicolgicos son
relevantes en la promocin del consumo inicial de drogas
(Botvin 2000a). En esta revisin, se obtuvo un nmero necesario
a tratar (NNT) igual a 33 para el consumo de marihuana, en
comparacin con el currculo habitual, lo cual signica que uno
de cada 33 estudiantes que reciben la intervencin no consumir
drogas gracias a la misma. Debido a que la prevalencia del
consumo de marihuana en la evaluacin en el brazo de control
de los ECA incluidos en esta comparacin (ver grco 08 de
la comparacin 02 habilidades versus currculo habitual) fue
de 16,5%, cinco de cada 33 estudiantes (16,5% de 33) consumir
esta droga. De ellos, uno se prevendra con la intervencin, lo
que corresponde al 20% de los que inician el consumo. Dado
que esta estimacin se basa en cuatro ECA que incluyeron 7287
estudiantes, con una prueba de heterogeneidad negativa, la
misma puede considerarse conable. Estos programas deben
elegirse como los ms efectivos en el contexto escolar, cuando
se planican intervenciones comunitarias complejas contra el
consumo de drogas.
El patrn de los resultados de esta revisin es consistente con
aquellos publicados por Tobler (Tobler 2000), a quien se le
reconoce el crdito de haber desarrollado y realizado la primera
revisin sistemtica sobre la efectividad de la prevencin
primaria del consumo de drogas, y de haberla mantenido
actualizada durante tantos aos (Tobler 1986; Tobler 1997).
Durante todo este perodo ella y sus colegas fueron casi los
nicos en proporcionar un resumen cuantitativo de la
efectividad, en el cual se consideraron la calidad del diseo
metodolgico y algunas covariables bsicas como el tipo de
programa, la interaccin, etc. Se han publicado muchas otras
revisiones. Algunas son revisiones sistemticas, pero no
proporcionan resultados de un metanlisis (Hansen 1992; Skara
2003), otras proporcionan un resumen de los resultados de
estudios sin calidad metodolgica alta (Bangert-Drowns 1988).
Otros se basan en programas especcos, como Ennett 1994, o
en un nico componente, como la participacin de los
compaeros (Mellanby 2000). Las revisiones ms recientes se
han basado en los componentes que aumentan la efectividad
del programa y han discutido el papel del mejor momento para
las intervenciones, las sesiones de apoyo, el contenido y la
administracin, (McBride 2003), o han propuesto y escalonado
recomendaciones para que los programas sean efectivos
(Cuijpers 2002a). Por lo tanto, existe un inters creciente en los
resmenes vlidos de la evidencia publicada en la literatura
cientca. Aun as, solo el estudio de Tobler 1986 es resultado
de una bsqueda y seleccin minuciosa de informes, evaluados
en concordancia con las caractersticas metodolgicas de su
diseo y es el nico con medidas de resumen.
La presente revisin aplic las normas Cochrane. Su objetivo
fue lograr un mejor resultado mediante el uso de ECA como
fuente principal, la clasicacin de los mismos segn su calidad
y la inclusin de sus datos en un metanlisis. Estas son las
diferencias principales entre este enfoque y el de Tobler 1997.
Los resultados de este trabajo parecen tener coherencia con las
revisiones Cochrane sobre la prevencin del consumo de alcohol
Pgina 13
entre los jvenes (Foxcroft 2004) y del hbito de fumar basada
en las escuelas, (Thomas 2004), aunque slo a corto plazo.
Pueden establecerse dos conclusiones a partir de esta
coherencia: primero, que es una conrmacin indirecta de la
teora que unica las caminos y los factores de riesgo para el
consumo de alcohol, tabaco y drogas entre los jvenes; segundo,
que favorece la administracin de una nica intervencin a nivel
escolar para prevenir el consumo inicial de todas las sustancias
nocivas.
Tambin debe remarcarse que la extensa cantidad de
investigaciones realizadas especialmente desde 1980, no gener
la evidencia esperada sobre la efectividad de la prevencin
primaria. Se seleccionaron 55 ECA y, para incrementar el
nmero de estudios, 33 EPC adicionales, pero slo una fraccin
de sus datos pudo utilizarse para la revisin. Numerosos ECA
se excluyeron debido a su calidad insuciente y cinco an se
encuentran en espera de evaluacin. Slo se incluyeron 29. Los
EPC fueron aun menos satisfactorios: 30 se excluyeron debido
a razones metodolgicas y slo se incluyeron tres. Podra
suponerse que 32 estudios fueron sucientes para establecer
un resumen slido y consistente de la evidencia sobre la
efectividad de las intervenciones para reducir el consumo de
drogas pero, sin embargo, este no fue el caso. Importantes
diferencias en los indicadores, las escalas y las puntuaciones
empleados para evaluar dicha efectividad, dicultan el resumen
de la evidencia: en un nico metanlisis se incluy un mximo
de cuatro de 29 ECA.
La revisin de las fuentes principales de este resultado deciente
muestra que la validez y la posibilidad de comparacin de los
resultados son aspectos que deben considerarse en estudios
futuros. La validez de los ECA sobre la prevencin primaria
de la drogadiccin se determina mediante:
asignacin aleatoria: el fracaso del proceso de asignacin
al azar fue la razn principal de la exclusin de 12 de los
21 ECA excluidos. Estos ensayos podran haberse incluido
si hubieran proporcionado el ajuste para los factores de
confusin;
desercin: dos ECA se excluyeron debido a su tasa de
desercin > 50% entre otras razones, y varios de los
incluidos presentaron tasas altas de desercin: cinco ECA
mostraron tasas mayores al 30% (Botvin 1990; Botvin
2001; Dent 2001; Hansen 1988; Sussman 2002). En tres
estudios no se mencion ninguna tasa (Hecht 1993; Kim
1989; Sexter 1984);
efecto del agrupamiento no controlado: el efecto del
agrupamiento surge porque si bien los nios son la unidad
de anlisis, los mismos se agrupan en clases y escuelas y,
en general, una escuela completa se asigna al azar a algn
brazo de intervencin. Este procedimiento reduce el
tamao de la muestra efectivo y genera variabilidad
aleatoria ya que hay una tendencia a que los resultados
muestren una similitud mayor entre dos nios del mismo
grupo, en comparacin con dos nios de diferentes grupos.
Frente a un poder estadstico determinado del estudio, la
muestra del mismo debe ampliarse para controlar este
efecto (Campbell 2001). Slo seis estudios (Botvin 2001;
Dent 2001; Ellickson 2003; Furr-Holden 2004; Hansen
1991; Sussman 2002) se disearon para considerar el
efecto del agrupamiento.
La validez de los EPC se determina mediante:
comparabilidad de los grupos: todos los sujetos deberan
pertenecer, tericamente, a la misma poblacin. Este
requisito se cumple fcilmente en los ensayos aleatorios,
sin embargo requiere algunos pasos adicionales en los
estudios de cohorte. El primer paso es que los sujetos
expuestos y no expuestos deben provenir de la misma
poblacin de base (p.ej. zona geogrca). El segundo paso
es la identicacin y el control de todos los factores de
confusin. Este ltimo fue la razn ms frecuente de la
exclusin de los EPC (21 de 30) y la poblacin de base
fue la razn en slo un caso (Short 1998);
relacin entre la exposicin y los resultados: algunos
estudios se basaron en encuestas colectivas, sin ninguna
relacin entre los datos previos y posteriores a la
evaluacin (Becker 1992; Dedobbeleer 2001; Hansen
1997; Kim 1982; Lewis 1972; Moskowitz 1983; Sarvela
1987; Skroban 1999); por lo tanto, no hubo ninguna
certeza acerca de si los estudiantes que reciban la
intervencin fueron los mismos que completaron el
cuestionario posterior;
otros problemas que sesgan la comparacin: por ejemplo,
en un estudio, los resultados de los grupos de intervencin
y de control se compararon con las evaluaciones previas
combinadas de ambos grupos (Freimuth 1997).
Finalmente, existe la cuestin de la generalizacin. Todos
excepto uno de los 29 ECA incluidos se realizaron en los
EE.UU. Debido a que el contexto social y las polticas sobre
las drogas de cada nacin tienen una inuencia signicativa
sobre la efectividad de sus programas de intervencin, la
generalizacin de los mismos resultara difcil de justicar.
CONCLUSI ONES DE LOS AUTORES
Implicaciones para la prctica
Los resultados de esta revisin sistemtica demuestran que los
programas que desarrollan las habilidades sociales individuales
son la forma de intervencin ms efectiva a nivel escolar para
la prevencin del consumo inicial de drogas.
Por otro lado, los programas basados en las escuelas que
proporcionan solamente informacin o se centran slo en la
dimensin afectiva, deben limitarse al contexto de evaluaciones
sumamente controladas y aleatorias.
Implicaciones para la investigacin
La evidencia que muestra la efectividad de la intervencin
basada en las habilidades es convincente debido a que se basa
en indicadores fuertes como el consumo de cannabis y herona,
Pgina 14
y los indicadores intermedios siguen la misma tendencia.
Adems, existe muy poca informacin de validez suciente
sobre el efecto a largo plazo de la intervencin. Los resultados
de esta revisin necesitan la corroboracin adicional en ensayos
aleatorios bien diseados y con seguimiento a largo plazo, y
tambin se requieren evaluaciones aleatorias de la efectividad
de los programas basados en las habilidades en otros pases que
no sean los EE.UU.
Tambin existe la necesidad de estudios slidos sobre el efecto
de los componentes individuales cuando se agregan a la
intervencin bsica: la inuencia de los compaeros, las
sesiones de apoyo y la participacin de los padres, que no se
han investigado sucientemente como para permitir
conclusiones conables. La interaccin entre los programas y
otras variables del contexto social tambin merece atencin.
Todos los estudios nuevos deben considerar el efecto del
agrupamiento, cada vez que sea necesario.
Dada la debilidad del modelo de causalidad terico, deben
rechazarse aquellos estudios que aborden slo las variables de
intervencin.
Los autores deberan intentar reducir el nmero de estudios
defectuosos al seleccionar diseos aleatorios, monitorizar la
observacin, reducir la desercin, seleccionar una estrategia
correcta de anlisis, hacer que sus resultados sean comparables
con aquellos ya publicados, elegir resultados "slidos" y escalas
previamente validadas y aceptadas e informar todos los datos
tiles para la estimacin de la validez: nmeros absolutos,
riesgos relativos, indicadores estadsticos.
Finalmente, se requieren estudios de colaboracin que combinen
los resultados de ECA de alta calidad, a los nes de un anlisis
ms detallado para asegurar un control ms exacto de la
heterogeneidad y una medicin ms precisa del tamao del
efecto asociado con las caractersticas signicativas de la
intervencin (edad objetivo, intensidad, etc.).
AGRADECI MI ENTOS
Damos las gracias a Paola Petroni, Valentina Comba, Simonetta
Lingua y Paride Angius por haber colaborado en la denicin
de las estrategias de bsqueda. Barbara Martin fue la
responsable de la recopilacin de los textos completos de los
artculos. Federica Mathis aport una contribucin valiosa en
la extraccin de los datos y en la evaluacin de la calidad de
los estudios.
El Dr. Robert Ali es el editor de contacto para la revisin.
POTENCI AL CONFLI CTO DE I NTERS
Ninguno.
FUENTES DE FI NANCI ACI N
Recursos externos
National Fund Against Drug - 1996 - Piemont Region
grant # 239/28.1 ITALY
Recursos internos
La informacin sobre los recursos de apoyo no est
disponible
REFERENCI AS
Referencias de los estudios incluidos en esta revisin
Bernstein 1987 {published data only}
Bernstein E, Woodal WG. Changing perceptions of riskiness in drinking,
drugs and driving: an emergency department-based alcohol and substance
abuse prevention program. Ann Emergency Med 1987;16(12):1350-4.
Botvin 1984 {published data only}
Botvin GJ, Baker E, Filazzola AD, Botvin EM. A cognitive-behavioral
approach to substance abuse prevention: one-year follow-up. Addictive
Behaviors 1990;15:47-63.
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cognitive-behavioral approach to substance abuse prevention. Addictive
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Botvin GJ, Baker E, Dusenbury L, Botvin EM, Diaz T. Long-term follow-up
results of a randomized drug abuse prevention trial in a white middle-class
population. JAMA 1995;273(14):1106-12.
*Botvin GJ, Baker E, Dusennbury L, Tortu S, Botvin EM. Preventing
adolescent drug abuse through a multimodal cognitive-behavioral approach:
results of a 3-year study. J Consulting Clin Psychology 1990;58(4):437-46.
*Botvin GJ, Schinke SP, Epstein JA, Diaz T. Effectiveness of culturally
focused and generic skills training approaches to alcohol and drug abuse
prevention among minority youths. Psychology Addictive Behaviors
1994;8(2):116-27.
Botvin GJ, Schinke SP, Epstein JA, Diaz T, Botvin EM. Effectiveness of
culturally focused and generic skills training approaches to alcohol and
drug abuse prevention among minority adolescents: two-year follow-up
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*Botvin GJ, Epstein JA, Baker E, Diaz T, Ill-Williams M. School-based
drug abuse prevention with inner-city minority youth. Journal of Child and
Adolescent Substance Abuse 1997;6(1):5-19.
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school-based preventive intervention. Prev science 2001;2(1):1-13.
Clayton 1991 {published data only}
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mediating variable for school-based prevention intervention. a two-year
follow-up of DARE. Health Communication 1991;3(4):229-39.
Pgina 15
Clayton RR, Cattarello AM, Johnstone BM. The effetiveness or Drug Abuse
Resistance Education (project DARE): 5-year follow-up results. Preventive
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Lynam DR, Milich R, Zimmerman R, Novak SP, Logan TK, Martin C et
al. Project DARE: no effects at 10-year follow-up. J Consulting Clin
Psychology 1999;67(4):590-3.
Cook 1984 {published data only}
*Cook R, Lawrence H, Morse C, Roehl J. An evaluation of the alternatives
approach to drug abuse prevention. Int J Addictions 1984;19(7):767-87.
Corbin 1993 {published data only}
*Corbin SKT, Jones RT, Schulman RS. Drug refusal behavior: the relative
efcacy of skill-based treatment. J Pediatric Psychology 1993;18(6):769-84.
Dent 2001 {published data only}
*Dent CW, Sussman S, Stacy AW. Project Towards No Drug Abuse:
generalizability to a general high school sample. Prev Med 2001;32:514-20.
Ellickson 1990 {published data only}
Bell RM, Ellickson PL, Harrison ER. Do drug prevention effects persist
into high school? How Project ALERT did with ninth graders. Prev Med
1993;22:463-83.
*Ellickson PL, Bell RM. Drug prevention in junior high: a multi-site
longitudinal test. Science 1990;247:1299-305.
Ellickson PL, Bell RM, Harrison ER. Changing adolescent propensities to
use drugs: results from Project ALERT. Health Education Quarterly
1993;20(2):227-42.
Ellickson PL, Bell RM, McGuigan K. Preventing adolescent drug use:
long-term results of a junior high program. Am J Public Health
1993;83(6):856-61.
Ellickson 2003 {published data only}
*Ellickson PL, McCaffrey DF, Ghosh-Dastidar B, Longshore DL. New
inroads in preventing adolescent drug use: results from a large scale trial
of project ALERT in middle schools. Adolescent Health
2003;93(11):1830-6.
Furr-Holden 2004 {published data only}
*Furr-Holden CDM, Ialongo NS, Anthony JC, Petras H, Kellam SG.
Developmentally inspired drug prevention: middle school outcomes in a
school-based randomized prevention trial. Drug Alcohol Dependence
2004;73:149-58.
Hansen 1988 {published data only}
*Hansen WB, Anderson Johnson C, Flay BR, Graham JW, Sobel J.
Affective and social inuences approaches to the prevention of multiple
substance abuse among seventh grade students: results from project
SMART. Preventive Medicine 1988;17:135-54.
Hansen 1991 {published data only}
*Hansen WB, Graham JW. Preventing alcohol, marijuana and cigarette use
among adolescents: peer pressure resistance training versus establishing
conservative norms. Prev Med 1991;20:414-30.
Palmer RF, Graham JW, White EL, Hansen WB. Applying multilevel
analytic strategies in adolescent substance use prevention research. Prev
Med 1998;27:328-36.
Hecht 1993 {published data only}
*Hecht ML, Corman SR, Miller-Rassulo M.. An evaluation of the Drug
Resistance Project: a comparision of lm versus live performance media.
Health Communication 1993;5(2):75-88.
Hurry 1997 {published data only}
*Hurry J, McGurk H. An evaluation of a primary prevention programme
for schools. Addiction Research 1997;5(1):23-38.
Jones 1990 {published data only}
*Jones RT, McDonald DW, Fiore MF, Arrington T, Randall J. A primary
preventive approach to children's drug refusal behavior: the impact of
Rehearsal-Plus. J Pediatric Psychology 1990;15(2):211-23.
Jones 1995 {published data only}
*Jones RT, Corbin SKT, Sheehy L, Bruce S. Substance refusal: more than
"Just Say No". J Child Adolescent Substance Abuse 1995;4(2):1-26.
Kim 1989 {published data only}
*Kim S, McLeod JH, Shantzis C. An outcome evaluation of refusal skills
program as a drug abuse prevention strategy. J Drug Education
1989;19(4):363-71.
Malvin 1985 {published data only}
*Malvin JH, Moskovitz JM, Schaps E, Schaeffer GA. Evaluation of two
school-based alternatives programs. J Alcohol Drug Education
1985;30(3):98-108.
Moskowitz 1984 {published data only}
*Moskowitz JM, Malvin JH, Schaeffer GA, Schaps E. An experimental
evaluation of a drug education course. J Drug Education 1984;14(1):9-22.
Ringwalt 1991 {published data only}
*Ringwalt C, Ennett ST, Holt KD. An outcome evaluation of Project DARE
(Drug Abuse Resistance Education). Health Education Research
1991;6(3):327-37.
Rosenbaum 1994 {published data only}
Ennett ST, Rosenbaum DP, Flewelling RL, Bieler GS, Ringwalt CL, Bailey
SL. Long-term evaluation of Drug Abuse Resistance Education. Addictive
Behaviors 1994;19(2):113-25.
Rosenbaum DP, Flewelling RL, Bailey SL, Ringwalt CL, Wilkinson DL.
Cops in the classroom: a longitudinal evaluation of drug abuse resistance
education (DARE). J Research Crime Delinquency 1994;31(1):3-31.
*Rosenbaum DP, Hanson GS. Assessing the effects of school-based drug
education: a six-year multilevel analysis of project DARE. J Research
Crime Delinquency 1998;35(4):381-412.
Ross 1998 {published data only}
*Ross C, Richard L, Potvin L. One year outcome evaluation of an alcohol
and drug abuse prevention program in a Quebec high school. Revue
Canadienne Sant Publique 1998;89(3):166-70.
Sexter 1984 {published data only}
*Sexter J, Sullivan AP, Wepner SF, Denmark R. Substance abuse:
assessment of the outcomes of activities and activity clusters in school-based
prevention. Int J Addictions 1984;19(1):79-92.
Sigelman 2003 {published data only}
*Sigelman CK, Bridges LJ, Leach DB, Mack KL, Rinehart CS, Sorongon
AG, Brewster AB, Wirtz PW. The efcacy of an education program to
teach children a scientic theory of how drugs affect behavior. Applied
Developmental Psychology 2003;24:573-93.
Snow 1992 {published data only}
Gersick KE, Grady K, Snow DL. Social-cognitive skill development with
sixth graders and its initial impact on substance use. Journal of Drug
Education 1988;18(1):55-70.
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1992;22(2):101-14.
Sussman 1998 {published data only}
Sussman S, Dent CW, Stacy AW. Project Towards No Drug Abuse: a
review of the ndings and future directions. Am J Health Behav
2002;26(5):354-65.
*Sussman S, Dent CW, Stacy AW, Craig S. One-year outcomes of project
towards no drug abuse. Prev Med 1998;27:632-42.
Pgina 16
Sussman 2002 {published data only}
*Sussman S, Dent CW, Craig S, Ritt-Olsen A, McCuller WJ. Development
and immediate impact of a self-instruction curriculum for an adolescent
indicated drug abuse prevention trial. J Drug Education 2002;32(2):121-37.
Sussman S, Sun P, McCuller WJ, Dent CW. Project towards no drug abuse:
two-year outcomes of a trial that compares health educator delivery to
self-instruction. Prev Med 2003;37:155-62.
Valentine 1998 {published data only}
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causal inference in adolescent drug prevention studies: methods and ndings
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Werch 1991 {published data only}
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and beliefs of parents and children. J School Health 1991;61(8):346-50.
Referencias de los estudios excluidos de esta revisin
Ambtman 1990
Ambtman R, Madak P, Koss D, Strople MJ. Evaluation of a comprehensive
elementary school curriculum-based drug education program. J Drug
Education 1990;20(3):199-25.
Becker 1992
Becker HK, Agopian MW, Yeh S. Impact evaluation of drug abuse
resistance education (DARE). J Drug Education 1992;22(4):283-91.
Bonaguro 1988
Bonaguro JA, Rhonehouse M, Bonaguro EW. Effectiveness of four school
health education projects upon substance use, self-esteem, and adolescent
stress. Health Education Quarterly 1988;15(1):81-92.
Botvin 2000
Botvin GJ, Grifn KW, Diaz T, Scheier LM, Williams C, Epstein JA.
Preventing illicit drug use in adolescents: long-term follow-up data from a
randomised control trial of a school population. Addictive Behaviors
2000;25(5):769-74.
Bry 1982
Bry BH. Reducing the incidence of adolescent problems through preventive
intervention: one and ve-year follow-up. Am J Community Psychology
1982;10(3):265-76.
Calafat 1984
Calafat A, Amengual M, Farres C, Monserrat M. Efcacy of a prevention
programme on the drugs, expecially on "take decisions", for specialists or
professors [Ecacia de un programa de prevencion sobre drogas,
especialmente centrado en la "toma de decisiones", segun sea desarrolado
por especialistas o por profesores de los alumnos]. Drogalcohol
1984;IX(3):147-69.
Cuijpers 2002
Cuijpers P, Jonkers R, de Weerdt I, de Jong A. The effects of drug abuse
prevention at school: the "Healthy School and Drugs" project. Addiction
2002;97:67-73.
De Jong 1987
De Jong W. A short-term evaluation of project DARE (Drug Abuse
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Education 1987;17(4):279-94.
De La Rosa 1995
De La Rosa Lopez A. La prevencion de las drogodependencias en el ambito
escolar. Una experiencia pratica evaluada. Thesis for Degree in Psychology
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Dedobbeleer 2001
Dedobbeleer N, Desjardins S. Outcomes of an ecological and participatory
approach to prevent alcohol and other drug abuse among multiethnic
adolescents. Substance Use Misuse 2001;36(13):1959-91.
Dent 1998
Dent CW, Sussman S, Hennesy M, Galaif ER, Stacy AW, Moss MA, Craig
S. Implementation and process evaluation of a school-based drug abuse
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1998;28(4):361-75.
DeWit 2000
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C, Rye B, Braun K, Wood E. Evaluating an in-school drug prevention
program for at-risk youth. Alberta J Educational Res 2000;46(2):117-33.
Donaldson 1994
Donaldson SI, Graham JW, Hansen WB. Testing the generalizability of
intervening mechanism theories: understanding the effects of adolescent
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Dukes 1997
Dukes RL, Stein JA, Ullman JB. Long-term impact of drug abuse resistance
education (DARE). Evaluation Review 1997;21(4):483-500.
Dukes RL, Ullman JB, Stein JA. Three-year follow-up of a drug abuse
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Duncan 2000
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Eggert 1994
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Fraguela 2002
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Freimuth 1997
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Graham 1990
Graham JW, Johnson CA, Hansen WB, Flay BR, Gee M. Drug use
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Grifn 2003
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Pgina 17
Hansen 1997
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LoSciuto 1988
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McAlister 1980
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Moberg 1990
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Moskowitz 1983
Malvin J, Moskovitz JM, Schaeffer GA, Schaps E. Teacher training in
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O'Donnell 1995
O'Donnell J, Hawkins JD, Catalano RF, Abbott RD, Day LE. Preventing
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Olton 1985
Olton AL. The effect of locus of control and perceptions of school
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J Drug Education 1985;15(2):157-69.
Pentz 1989
Chou CP, Montgomery S, Pentz MA, Rohrbach LA, Johnson CA, Flay BR,
MacKinnon DP. Effects of a community-based prevention program on
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Dwyer JH, MacKinnon DP, Pentz MA, Flay BR, Hansen WB, Wang EYI,
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MacKinnon DP, Anderson Jonhson C, Pentz MA, Dwer JH, Hansen WB,
Flay BD, Wang EYI. Mediating mechanisms in a school-based drug
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Petoskey 1998
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Prinz 2000
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Raynal 1996
Raynal ME, Chen WW. Evaluation of a drug prevention program for young
high risk students. International Quarterly of Community Health Education
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Rollin SA, Rubin R, marcil R, Ferullo U, Buncher R. Project KICK: a
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Sarvela 1987
Sarvela PD, McClendon EJ. An impact evaluation of a rural youth drug
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Schinke 2000
Schinke SP, Tepavac L, Cole KC. Preventing substance use among native
american youth: three-year results. Addictive Behavior 2000;25(3):387-97.
Shope 1996
Shope JT, Copeland LA, Kamp ME, Lang SW. Twelfth grade follow-up
of the effectiveness of a middle school-based substance abuse prevention
program. J Drug Education 1998;28(3):185-97.
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school-based substance abuse prevention program. J Drug Education
1996;26(4):323-37.
Short 1998
Short JL. Evaluation of a substance abuse prevention and mental health
promotion program for children of divorce. J Divorce Remarriage
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Skroban 1999
*Skroban SB, Gottfredson DC, Gottfredson GD. School-based social
competency promotion demonstration. Evaluation Review 1999;23(1):2-27.
Pgina 18
Snow 1997
Snow DL, Tebes JK., Ayers TS. Impact of two social-cognitive interventions
to prevent adolescent substance use: test of an amenability to treatment
model. J Drug Education 1997;27(1):1-17.
Stevens 1996
Stevens MM, Freeman DH, Mott L, Youells F. Three-year results of
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Valentine 1998a
*Valentine J, Gottlieb B, Keel S, Grifth J, Ruthazer R. Measuring the
effectiveness of the Urban Youth Connection: the case for dose-response
modelling to demonstrate the impact of an adolescent substance abuse
prevention program. Journal of Primary Prevention 1998;18(3):363-87.
Villalb 1993
Villalb JR, Aub J, Gonzalez AG. Results of a school prevention
programme on the substances abuse: project of a pilot study in Barcellona
[Resultados de un programa escolar de prevencion del abuso de sustancias
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Young 1997
Young M, Kelley RM, Denny G. Evaluation of selected life-skill modules
from the contemporary health series with students in grade 6. Perceptual
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Referencias de los estudios en espera de evaluacin
Calafat 1989
Calafat A, Amengual M, Guimerans C, Rodriguez-Martos A, Ruiz R. "You
decide" 10 years of a school based prevention programme ["Tu decides":
10 anos de un programa de prevencion escolar]. Addiciones
1995;7(4):509-26.
*Calafat A, Amengual M, Mejias G, Borras M, Palmer A. Valuation of the
school based prevention programme "You decide" [Evaluacion del programa
de prevencion escolar "Tu decides"]. Addiciones 1989;1(2):96-111.
D'Amico 2002
D'Amico EJ, Fromme K. Brief prevention for adolescent risk-taking
behavior. Addiction 2002;97:563-74.
Eisen 2002
*Eisen M, Zellman GL, Massett HA, Murray DM. Evaluating the
Lions-Quest "Skills for Adolescence" drug education program: rst-year
behavior outcomes. Addictive Behav 2002;27:619-32.
Eisen M, Zellman GL, Murray DM. Evaluating the Lions-Quest "Skills for
Adolescence" drug education program: second-year behavior outcomes.
Addictive Behav 2003;28:883-97.
Hecht 2003
Hecht ML, Marsiglia FF, Elek E, Wagstaff DA, Kulis S, Dustman P,
Miller-Day M. Culturally grounded substance use prevention: an evaluation
of the keepin' it REAL curriculum. Prevention Science 2003;4(4):233-48.
Perry 2000
Perry CL, Komro KA, Veblen-Mortenson S, Bosma LM, Farbakhsh K,
Munson KA et al. A randomized controlled trial of the middle and junior
high school DARE and DARE Plus Programs. Arch Pediatr Adolesc Med
2003;157:178-84.
*Perry CL, Komro KA, Veblen-Mortenson S, Bosma LM, Munson KA,
Stigler MH et al. The Minnesota DARE PLUS Project: creating community
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Pgina 19
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* El asterisco seala los documentos ms importantes para este estudio
Pgina 20
TABLAS
Characteristics of included studies
Bernstein 1987 Study
RCT.
Quality Class: B.
Subjects were randomly assigned to either the experimental or the control group.
Methods
33 7th-grade students from a mid-school in Abuquerque, New Mexico (USA). January
1985 - September 1985.
Participants
ASAP (Alcohol and Substance Abuse Prevention Program).
Subjects in both the experimental and control group received a semester-long
standardized Berkeley Health Education Curriculum, but only the experimental group
(n=17) received the ASAP program, based on observation and interview of patients
with alcohol and substance abuse problems. The ASAP program was taught at the
Emergency Department (ED) of the University. Medical students, ED staff and teacher
supervised the visits. The educational techniques used included traditional work-book
and didactic format, role-plays exercises, small group exercises, and out of class
assignments.
Interventions
Subjects were measured prior to the program, immediately after the program, and at
eight months after the program, using a specific anonymous questionnaire. Dependent
measures included:
- knowledge: consequences of use
- attitudes: perceptions of riskiness of drug use, and drinking or drug use combined
with driving
- behavior: self-reported frequency of alcohol and drug use and driving behavior in the
last week and month
- perceived significance and positive function of drinking and drug use
Outcomes
No data suitable for inclusion in the meta-analyses.
Attrition: 0% (unclear)
Notes
B Allocation concealment
Botvin 1984 Study
RCT.
Quality Class: B.
The 10 schools participating in the study were randomly assigned to three conditions;
students were the unit of analysis.
Methods
1311 7th-grade students from 10 suburban New York junior high schools, USA. Participants
Life Skills Training Program: a multicomponent substance abuse prevention program
consisting of five major components: cognitive, decision making, anxiety, managing,
social skills training, self improvement, with the following experimental conditions
(factorial design):
- substance abuse prevention program implemented by older students (4 schools)
- substance abuse prevention program implemented by regular classroom teachers (4
schools)
- prevention program with booster sessions implemented by older peer leaders
- prevention program with booster sessions implemented by regular classroom teachers
- pretest/multiple posttest control group (2 schools)
Interventions
Pgina 21
All of the students in the study were pretested by questionnaire for self-reported tobacco,
alcohol, marijuana use status as well as on several cognitive, attitudinal and personality
variables. Saliva samples were collected immediately prior to the completion of the
self-report section of the questionnaire utilizing a variant of the "bogus pipeline"
procedure.
Approximately four months after the pretest, as well as one year after the initial post-test
all students were tested again by questionnaire, and saliva samples were once again
collected.
Outcomes
No data suitable for inclusion in the meta-analyses: the absolute number of subjects
in the groups are not given. Authors contacted without reply.
Attrition at post-test: 9.6%. Analysis sample n=1185.
Attrition at one year follow-up: 24%.
Notes
Botvin 1990 Study
RCT.
Quality Class: B.
On the basis of the existing smoking levels, schools were divided into terziles and
randomly assigned to the experimental conditions. Students were used as unit of
analysis.
Methods
5954 7th-grade students from 56 schools in the New York State - USA, fall of 1985-1986
school year.
3597 students provided data after 6 years, in 1991.
Participants
Life Skills Training Program: a cognitive-behavioral resistance skills prevention program,
with three experimental conditions:
- E1: 15 class periods in 7th-grade+boosters in 8th-grade and 9th-grade
with one day formal training of teachers and implementation feedback
- E2 like E1 but with videotape teacher training and no implementation feedback
- control: as usual.
Interventions
Questionnaires measured monthly and weekly prevalence of cigarettes smoking,
alcohol, marijuana and other drugs consumption, knowledge attitude and normative
beliefs, skills and psychologal characteristics. All students were pretested by
questionnaire administered by project staff immediately before the implementation of
the prevention program. Breath samples were collected in a variation of the "bogus
pipeline" procedure. Before the pre-test, students were randomly selected within each
class to receive one of three questionnaire forms (A, B or C). Post-test was administered
during 12th-grade, and follow-up test after 6 years.
Outcomes
Attrition at post-test: 25%.
High fidelity (students who received at least 60% of the prevention program) sample
at post-test: n=3684 (attrition: 38.1%).
782 students were excluded from the analysis sample because of failure to meet the
inclusion criteria.
Attrition after 6 years: 39.6%. Analysis sample: n=3597.
Attrition of high fidelity sample: 53.8% (analysis sample: n=2752).
The full sample data was used in the meta-analyses.
Notes
Pgina 22
Botvin 1994 Study
RCT.
Quality Class: B.
6 schools were matched according to demographics and randomly assigned to receive
one of three interventions.
Methods
757 7th-grade students from 6 junior high schools in New York, (USA), school year not
specified.
456 students provided follow-up data in the 9th-grade.
Participants
Three experimental conditions:
- broad-spectrum life skills training
- culturally focused intervention
- information-only control
Students in the two experimental conditions participated in 15-session curriculums
taught at an average rate of 2 sessions per week.
The main purpose of both interventions was to facilitate the development of personal
and social skills for coping with social influences to smoke, drink or use drugs. The life
skill training approach was implemented with all students in a classroom setting, whereas
the culturally focused intervention approach targeted high-risk students and involved
group counselling conducted by professionally trained leaders and peers.
Students received the intervention during 7th-grade, and booster sessions in 8th-grade.
Interventions
All students completed a pretest questionnaire that measured self-reported behavioral
intentions to drink alcoholic beverages or use illict drugs as well as cognitive, attitudinal,
and personality variables. Carbon monoxide breath samples were also collected.
Approximately 4 months after the pretest, students were posttested using the same
questionnaire, and carbon monoxide samples were collected again.
The measurements were repeated again 2 years later in the 9th-grade.
Outcomes
Attrition at post-test: 16%. Analysis sample: n=639.
Attrition at follow-up (9th-grade): 40%.
Notes
Botvin 1997 Study
RCT.
Quality Class: B.
The 7 schools participating in the study were assigned to two conditions; students were
the unit of analysis.
Methods
833 7th-grade students from 7 junior high school, New York, USA. Participants
Drug Abuse Prevention Curriculum, teaching social resistance skills, anti-drug norms
and materials designed to facilitate the development of important personal and social
skills.
The participating schools were assigned to receive a psychosocial drug abuse prevention
program or to serve as a "standard care" control group. The intervention group received
15-session psychosocial program consisting in lessons, behavioral exercises,
video-tapes administration, taught by regural classrooms teachers.
Interventions
All students provided pre-test and post-test data approximately three months after the
pre-test.
A specific questionnaire was used to measure self-reported drug use behavior along
with relevant cognitive, attitudinal and personality variables. carbon monoxide breath
samples were also collected at both the pretest and the posttest to enhance the validity
of self-reported data.
Outcomes
Pgina 23
Unclear study design: RCT?
Attrition: 13%.
Notes
Botvin 2001 Study
RCT.
Quality Class: B.
Blocked randomized design. Prior to randomization, schools were surveyed and diveded
into high, medium, or low smoking prevalence. From within these groups, each of the
29 partecipating schools were randomized to either receive the intervention (16 schools)
or be in the control group (13 schools). At the analysis stage generalized linear models
analysis of covariance and generalized estimating equations independent method were
used. Additional analysis were conducted to control for intracluster correlation among
students within schools. Regression analysis were conducted to determine the effects
of mediating variables.
Methods
5222 7th-grade students from 29 New York City public schools (USA), school year not
specified. 3621 (69%) students were included in the panel sample as economically
disadvantaged minority adolescents.
Participants
Drug Abuse Prevention Program, teaching drug resistance skills, anti-drug norms, and
facilitating the development of personal and social skills. These skills were taught using
a combination of teaching techniques including group discussion, demonstration,
modeling, behavioral rehealsal, feedback and reinforcing, and behavioral homework
assignments. Intervention materials included teacher's manual with detailed
lesson-plans, student handouts, and video-material demonstrating the personal and
social skills being taught in the prevention program by same age minority adolescents.
Schools were randomly assigned to one of two conditions.
- prevention program: students (n=2144) received 15 sessions in the 7th-grade and 10
booster sessions in the 8th-grade
- control group: students (n=1477) received the program that was normally in place at
New York City schools.
The program was implemented by regular classroom teachers who had attended a
1-day-teacher-training workshop.
Interventions
Students provided data at the pre-test and post-test (grade 7), as well as at the 1-year
follow-up (grade 8).
Self-reported drug use behavior was assessed by a questionnaire along with relevant
cognitive, attitudinal, and skills variables. Questionnaire were administered during a
regular 40-minute classroom period by a team of 3 to 5 data collectors of ethnic-racial
backgrounds to match that of participants. Carbon monoxide breath samples were also
collected at all three assessments.
Use of drugs was measured with specific scales
Outcomes
Attrition at post-test and follow-up: 30.6%.
Data for inclusion in the tables were obtained from authors.
Notes
Clayton 1991 Study
RCT.
Quality Class: B.
23 elementary schools were randomly assigned to receive the DARE curriculum, 8
schools were randomly selected as comparison group.
Methods
Pgina 24
2071 6th-grade students in the Lexington-Fayette County public schools, Kentucky
(USA), 1987-1988 school year.
Follow-up evaluation each subsequent year until 10th-grade, and again at 20 years
age.
Participants
DARE program. Cognitive, affective and social skills strategies, aimed to increase
students' awareness of adverse consequences of drug use, build self-esteem, improve
decision making and assertiveness in social settings.
DARE intervention was delivered by police officers in 1-hr sessions over 16 weeks.
Control group students received drug educaton lessons which varied across schools.
Intervention group: n=1550.
Control group: n=521.
Interventions
Students completed a 154-item questionnaire prior to receiving DARE curriculum in
the 23 treatment schools, or prior to the drug unit in the health curriculum in the 8
comparison schools. Posttest were administered approximately 4 months after pretest,
shortly after the completion of the program, and each subsequent year through the
final datacollection effort in the spring of 1992 when most were in 10th-grade.
Frequency of past year use of cigarettes, alcohol, and marijuana, attitudes towards
cigarettes, alcohol and marijuana, attitudes towards drugs on a general level, ability to
resist negative peer pressure, perceived peer use were measured.
Outcomes
No data suitable for inclusion in the meta-analyses. Authors contacted without reply.
Attrition:
- 7% at posttest
- 18.4% at 7th-grade
- 51.6% at 19-20 years age (analysis sample: n=1002).
Notes
Cook 1984 Study
RCT.
Quality Class: B.
Students eligible for the program were randomly assigned to either the PAY alternative
classes or to no-treatment control group.
Methods
283 junior and senior high school students (volunteers) from the public schools of
Milwaukee, Wisconsin (USA). 1979-1980 and 1980-1981 school years.
Participants
PAY program (Positive Alternatives for Youth), aimed to increase alternatives to drug
abuse, such as personal awareness, interpersonal relations, self-reliance development,
vocational skills, aesthetic and intellectual experiences, social-political involvement,
sexual expression, meditation, spiritual-mystical experiences and creative experiences.
The classes met two to three times a week during regular school hours and were
conducted jointly by a PAY staff person and a teacher-trainee. The alternatives classes
consisted of major units, presented over a semester: orientation, communications,
self-concept, self-care, activities. The PAY class involved one or two experiential
exercises interspersed with lectures and discussion, for a maximum of 15 students.
Interventions
Pgina 25
All students were assessed on criteria of interest both before and at the end of the
semester-long PAY classes, using specific questionnaires.
The investigated outcomes included drug and alcohol use, activities participation,
feelings and remedies, marijuana and alcohol involvement, attitudes and perceptions
of one's social skills, peer pressure resistance, self-esteem, future orientation, stress
management, attitudes towards drugs and alcohol, responsible use, activity attitudes.
.
Outcomes
All the PAY students and the control group were volunteers.
Attrition at post-test (first year): 14.4% for the experimental group, 10.9% for the control
group.
Attrition at post-test (second year): 17.1% for the experimental group, 15.2% for the
control group.
Notes
Corbin 1993 Study
RCT.
Quality Class: B.
At the analysis stage Odds Ratios were examined by means of logistic regression
models, adjusting for ethnicity, socio-economic status, gender, school type (public or
private), grade and time trend.
Methods
74 3rd-grade children from a primarily lower middle-class neighborhood attending an
elementary school in southwestern Virginia, USA.
Participants
Students were randomly assigned to one of three conditions.
- Rehearsal-plus condition: children (n=22) were taught drug knowledge, assertiveness
skills, decision-making skills, rationale and specific drug refusal skills in the context of
a skills-based strategy
- General Information condition: children (n=16) were taught the same components at
a more global level with the exception of rationale
- control group: children (n=19) received drug education only after they received
postassessment.
Interventions
At pre and post test, all children were individually assessed on: decision making,
rationale, drug knowledge, assertiveness, general knowledge, and behavioral skills,
using the Prevention of Child Drug Use Assessment Instrument, the Life Skills Training
Student Questionnaire and the Drug Refusal Behavioral Situations Scale. At follow-up
(4 weeks after the intervention), only subjects in experimental conditions were assessed.
Outcomes
Attrition: 23%. Analysis sample n=57. Notes
Dent 2001 Study
RCT.
Quality Class: B.
Three general public high schools were randomly selected from general high schools;
the classes were then randomly assigned to one of two experimental conditions. Classes
are the unit of assignment and analysis.
At the analysis stage, a SAS Proc Mixed procedure was used in order to handle
clustered data in the context of ANCOVA analysis.
Methods
1208 9th, 10th and 11th grade students in general high schools in Los Angeles (USA). Participants
Pgina 26
Project Towards No Drug abuse (TND).
The classroom-based drug abuse prevention program consisted of three 50-minute
sessions per week for 3 consecutive weeks during regularly scheduled class periods,
with a health motivation-social skills-decision making approach. The first 3 lessons
motivates students to listen to prohealth programming and provides them with effective
listening skills. The second 3 lessons instructed students in chemical dependency
issues and alternative coping skills, whilst the third 3 lessons encourages the students
making non-drug-use choices.
Two groups:
- TND program
- standard care condition
Interventions
A school-wide pretest survey was conducted at each of the 26 classrooms immediately
before the program implementation and one year later.
A specific questionnaire was used to collect data about demographic variables, drug
use, socio-economic data, prevalence estimate of peer use, perceived stress, sensation
seeking, assertiveness measures. Responses were provided on 11-point rating scales.
Outcomes
Attrition at one year: 37.1%. Analysis sample n=679.
Notes
Ellickson 1990 Study
RCT.
Quality Class: B.
Three methods were used: blockage by district, restricted assignment, and randomized
assignment of schools.
Moreover, regression methods were used at the analysis stage to adjust for chance
differences among the groups.
Methods
6527 7th-grade students from 30 schools in California and Oregon (USA). 1984-1990. Participants
Project ALERT, targeting alcohol, cigarettes and marijuana use, seeking to motivate
the students to resist pro-drug influences and to give them the skills to do so. The
schools were randomly assigned to one of three experimental condition:
- project ALERT taught by a teacher alone
- project ALERT taught by the teacher assisted by teen leaders
- control group
When students in the treatment groups reached eight grade, they received three booster
lessons.
Interventions
Beliefs about consequences of using substances, perceptions about use in peers,
resistance self-efficacy, expectations of use in next 6 months, use of alcohol, cigarettes
and marijuana, measured by a questionnaire administered before and after delivery of
7th-grade curriculum (baseline and 3 months later), before and after 8th-grade booster
lessons (12 and 15 months after baseline), and once each during grades 9, 10, and
12 (24, 36 and 60 months after baseline).
Outcomes
Attrition: 18% at post-test .
Attrition: 36-40% at 9th-grade follow-up (analysis sample: n=3852).
Attrition: 63-67% at 10th-12th-grade follow-up.
Notes
Pgina 27
Ellickson 2003 Study
RCT.
Quality Class: B.
Three methods were used: blockage by geographic region, community size and type,
restricted assignment, and randomized assignment of schools.
At the analysis stage, an adjustment for multiple baseline covariates was performed,
including blocking covariates. Missing data for covariates were included using a
Bayesian model. To account for possible intraschool correlation a generalized estimating
equation and empirical sandwich standard errors were used.
Methods
5412 7th-grade students enrolled from 55 middle schools in South Dakota (USA),
1997-1999 school years.
4689 students completed baseline survey, 2810 students in the Program Group, 1879
students in the Control Group.
Participants
Project ALERT, targeting alcohol, cigarettes and marijuana use, seeking to change
student's beliefs about drug norms and consequences, and to help them to identify and
resist pro-drug pressures.
Two experimental condition:
- project ALERT (revised)
- control group
The administered program is a revised version of the original Project ALERT. The
revised curriculum consisted in 11 lessons in 7th-grade and 3 in 8th-grade, using
interactive teaching methods (question-and-answer techniques and small group
activities).
Interventions
Use of alcohol, cigarettes and marijuana, measured by a questionnaire administered
before the delivery of 7th-grade curriculum and after the administration of 8th-grade
lessons (approximately 18 months later).
Outcomes
Attrition at post test (18th months): 8.8%.
Analysis sample n=4276, 2553 intervention group, 1723 control group.
Notes
Furr-Holden 2004 Study
RCT.
Quality Class: B.
First-grade students were randomly assigned to one of the three experimental condition,
with balancing for male-female ratio. At the analysis stage, the Taylor series linearization
and GEE approaches were used in order to take into account of the clustering of youths
within classrooms. Intention to treat analysis was performed. Subgroup variation was
explored introducing baseline covariates and product-terms in the model.
Methods
678 1st-grade students from nine primary schools in USA, 1993 school year. Follow-up
at 6th, 7th and 8th-grade. 192 students in the classroom-centered intervention and 178
students in the standard educational setting participated in the follow-up.
Participants
Pgina 28
- Classroom-centered intervention (n=192)
- Family-school partnership intervention (n=178)
- Standard educational setting (n=196)
The classroom-centered intervention consisted of three components: curricular
enhancements, improved classroom behavior management practices, and
supplementary strategies for children not performing adequately. An interactive
read-aloud component was added to increase listening and comprehension
skills.Strategies employed with respect to academic non-responders included individual
or small group tutoring, and modifications in the curriculum to address individual learning
styles.
Interventions
Baseline assessments were completed at school entry, after consent, and included:
teacher ratings of the targeted early risk behaviors of attention/concentration problems,
aggressive and shy behaviors, parent disciplinary practices. Follow-up assessments
with respect to drug involvement were conducted during the spring of 6th through 8th
grades. Audio computer-assisted self-interview (ACASI) methods were used to
administer standardized item sets. Specific measures at baseline were: parent
management skills and practices measured with SIPMSP questionnaire (parental
monitoring and supervision, inconsistent discipline, parental reinforcement and
involvement, rejection of the child), and teacher observation of classroom adaptation
measured with TOCA-R questionnaire (accepting authority, social participation,
concentration and being ready for work). Measures at follow-up included: tobacco,
alcohol, marijuana, inhalants and other illegal drug use.
Outcomes
Attrition at follow-up (6th, 7th, 8th grade): 16%.
Analysis sample n=566, 192 intervention group, 178 control group.
Notes
Hansen 1988 Study
RCT.
Quality Class: C.
Schools were randomly assigned to intervention and control conditions using a
multi-attribute approach.
Methods
2863 7th-grade students from 44 junior high school complexes in the Los Angeles
Unified School District (USA).
Academic year 1982-83. Follow-up at eight grade.
Participants
Project SMART (Self Management and Resistance Training).
- Affective curriculum
- Social influences curriculum
- Control condition.
The social skills program included teaching students about the various sources of social
pressure to use drugs, techniques for resisting them, and role-play opportunities for
practicing the resistance techniques.
The affective program focused on personal decision-making, values clarification, and
stress management techniques.
Both experimental conditions were taught by health educators alternated with regular
classrooms teachers in 12 sessions.
Interventions
Pre and post-test data were collected using specific questionnaires and by the collection
of saliva specimens. Questionnaire items assessed tobacco, alcohol and marijuana
use, demographics and a number of other psychosocial constructs.
Post-test was administered 12 and 24 months later.
Outcomes
Pgina 29
in the groups are not given. Authors contacted: data no more available.
Attrition at 12 months: - Social: 37%
- Affective: 30%
- Control: 39%.
Attrition at 24 months:
- Social: 60%
- Affective: 37%
- Control: 60%.
Notes
Hansen 1991 Study
RCT.
Quality Class: B.
Schools were stratified by size, test scores, and ethnic composition and randomly
assigned to receive one of four intervention programs.
In the first paper a general linear model analysis was used using classrooms as unit
of analysis. In the second paper the analysis was repeated using a combination of
multilevel strategies and ordinary least-squares analysis to take into account of the
discrepancy between unit of analysis and unit of randomization.
Methods
3027 7th-grade students from 12 junior high school in Los Angeles and Orange Counties,
California (USA). School year 1987-88. Follow-up at one and two years.
Participants
AAPT program (Adolescent Alcohol Prevention Trial).
Four experimental conditions:
- Information (ICU)
- Resistance Training (RT)
- Normative Education
- Combined
The Information program consisted in four 45-minutes lessons about the social and
health consequences of using alcohol and other drugs.
The Resistance Training
program consisted of four lessons about the consequences of using substances plus
five lessons focused on resistance skills. The Normative Education program included
four lessons plus five lessons about perceptions of peer drug use, trying to establish
a conservative normative school climate regarding substance use.
The Combined program consisted in three lessons about information, three and one-half
lessons teaching resistance skills, and three and one-half lessons establishing
conservative norms.
programs were delivered by project staff.
Interventions
Students were pre-tested using a questionnaire assessing use of alcohol, marijuana
and cigarettes. The same questionnaire was used at one year and two years follow-up.
Outcomes
Attrition: 22% at one year follow-up.
Analysis sample n=2370.
Attrition: 46% at two years follow-up.
Notes
Pgina 30
Hecht 1993 Study
RCT.
Quality Class: C.
Classes were randomly assigned to one of four intervention conditions and one control
condition.
Methods
465 students from a high school in soutwestern USA. Participants
Drug Resistance Strategies Project.
Five experimental conditions:
- film only
- film plus discussion (n=99)
- live performance
- live performance plus discussion
- control condition (n=89)
Four primary resistance strategies were identified (refuse, explain, avoid, leave) and
categorized into the REAL system. A writer developed a screenplay based on the REAL
system and prevention education curriculum information; two teen focus groups validated
the materials and the approach. The resulting training curriculum utilized actual narrative
accounts that were performed by actors and couched in a musical drama format. The
film curriculum was produced on film and transferred to videotape; the screenplay was
then adapted into a live performance format.
Performances were 34-minutes long. A 20-minutes discussion followed the performances
and was directed by discussion leaders.
Interventions
Students were pre-tested with a questionnaire containing demographic informations,
current usage and amount, use of resistance skills, confidence and difficulty of
resistance, attitudes, perceived normative support for use of drugs and alcohol, and
use of planning to avoid drugs.
An immediate post-test was administered 1 day after the intervention (both in the
intervention and control groups). Follow-up post-test was administered 1 month after
the intervention.
Outcomes
Unclear attrition rate.
Unclear results.
Notes
Hurry 1997 Study
RCT.
Quality Class: B.
6 classrooms were randomly allocated in the intervention or the control group.
Methods
120 students attending a school in Hackney (London), aged 7-10 years. Participants
Project Charlie (Chemical Abuse Resolution Lies in Education). Based on lessons
focused on increase of self-esteem, decision making power, resistance skills and
knowledge, taugth by an external trained teacher.
Interventions
Pgina 31
- Resistance and decision making skills were measured by an adaptation of the
Alternatives and Concequences Test
- Self esteem was measured using the Harter Self-Perception Profile for Children
Subscales
- Knowledge
- Intention to use and substance including tobacco and alcohol use were measured
with ad hoc tools
All the children were assessed just before Project Charlie was introduced to the school,
and re-tested at the end of the year.
Outcomes
Attrition: 10.9% in the intervention group.
Attrition: 17.9% in the control group.
Risk of cross-contamination because only one school was included for each arm.
Notes
Jones 1990 Study
RCT.
Quality Class: B.
Children were randomly assigned to one of the three experimental condition.
Methods
42 3rd-grade children in a public school in a rural community of southwestern Virginia
(USA).
Participants
Three experimental conditions: rehearsal-plus (n=15), traditional (n=15) and attention
control (n=12).
Children in rehearsal-plus group were taught specific drug refusal techniques and
appropriate social skills, and were provided a rationale for each response.
Children in the traditonal condition received instruction derived from a "Just to say no"
drug program, based on discussions about peer pressure situations.
Members of the attention control group received more formalized lecture and discussion
based instruction on drug abuse, without discussing the subjects of peer pressure.
Five undergraduate psychology students served as trainers.
Interventions
All children were individually assessed before the intervention; immedialtely following
the last training session on the 2nd day, post-training assessment on behavioral,
knowledge and self-efficacy measures were obtained.
Outcomes
Short-term evaluation.
Attrition: 0%.
Notes
Jones 1995 Study
RCT.
Quality Class: B.
Children were randomly assigned to one of the three experimental condition.
Methods
34 3rd-grade children from a primarily lower middle-class neighborhood attending an
elementary school in a rural community of southwestern Virginia, USA.
Participants
Pgina 32
Students were randomly assigned to one of three conditions.
- Rehearsal-plus condition: children (n=14) were taught drug knowledge, assertiveness
skills, decision-making skills, rationale and specific drug refusal skills in the context of
a skills-based strategy
- General Information condition: children (n=12) were taught the same components
with the exception of rationale; addictionally, they received training in general
knowledge/self-esteem
- control group: children (n=8) received no training
The program was administered by eight undergraduate psychology majors. Children
in both experimental conditions were trained in groups of three across three consecutive
days.
Interventions
At pre and post test, all children were individually assessed on: decision making,
rationale, drug knowledge, assertiveness, general knowledge, and behavioral skills,
using the Prevention of Child Drug Use Assessment Instrument, the Life Skills Training
Student Questionnaire and the Drug Refusal Behavioral Situations Scale.
Outcomes
Short-term evaluation.
Attrition: 0%.
Notes
Kim 1989 Study
RCT.
Quality Class: C.
Classrooms were randomly selected for treatment and control groups, but students
were used as unit of analysis.
Methods
7th grade students attending the Charlotte-Meckelenburg public school in North Carolina,
USA.
235 students in the intervention group, 132 students in the control group.
Participants
WHOA, A Great Way to Say No: a structured refusal skills program.
Students in the WHOA class are taught a three-session program with each session
lasting about 50 minutes. Students are given strategies for dealing with situations in
which the pressure is extended or increased. The program is taught by 7 volunteers
of the Charlotte Junior League trained by the professional staff of the Drug Education
Center for 14 hours.
10 treatment classes, 6 control classes.
Interventions
Drug attitutes, social attitudes, rebelliousness, self-esteem, measured by a standardized
evaluation questionnaire, the Student Attitudinal Inventory (SAI), administered before
(October 1987) and after (May 1988) the invervention.
Outcomes
Unclear attrition rate. Notes
Malvin 1985 Study
RCT.
Quality Class: C.
Students were matched on the basis of course selection, grade level, sex and grade
point average for the prior semester, and randomly assigned to the groups.
Methods
Pgina 33
8th and 9th grade students volunteering for two service opportunity courses
(Cross-Age-Tutoring and School Store). Initial sample included 29 students in each
condition in Cross-Age-Tutoring and 28 students in each condition in School Store.
Spring 1979-Spring 1980.
Follow-up: Spring 1981. California, USA.
Participants
Cross-Age-Tutoring: students were taught tutoring and communication skills and spent
four days a week tutoring elementary students. School Store: students were taught
business and interpersonal skills and operated an on-campus store.
Interventions
Pretest data were obtained from students with the Student Questionnaire and the Self
Observation Scale, the first measuring locus of control for success and for failure,
academic self-esteem, attitudes toward school, and perceived peer attitude toward
school, the second measuring the ways students perceive themselves and their
relationships to their peers, their teachers and their school. Drug-related pretest data
were collected with the DAS, assessing lifetime and current use, attitudes toward use,
intention to use, general drug attitude, drug knowledge and the perceived benefits and
costs.
Post test data were obtained with the DAS and a revised version of the Student
Questionnaire, administered in the Spring after the participation in the courses, and
one year later.
Outcomes
Attrition at the post-test: 20-25%.
Attrition at one year: 52-63%.
Notes
Moskowitz 1984 Study
RCT.
Quality Class: B.
Social study classes were paired on pre-test attitudes toward and involvement in alcohol,
cigarette and marijuana use; one class in each pair was then randomly assigned to
receive the drug education course. Students were used as unit of analysis.
Methods
7th and 9th grade students attending two junior high schools in a suburban community
in Northern California, USA.
Second semester of the academic year 1980-81. 473 students enrolled (n=237 in the
experimental classes, n=236 in the control classes), of which 399 completed both the
pretest and the posttest, and 352 completed both the pretest and the follow-up.
Participants
Napa Project. The drug education course consisted of twelve weekly, 45-minute sessions
conducted from February through March 1981, during regular class time in social studies
classes. Sessions were focused on motivation and decision-making skills, personal
goals, assertiveness, knowledge.
Intervention group, n=237.
Control group, n=236.
Interventions
Drug and Alcohol Survey questionnaire (DAS) was employed for all testing occasions.
Pretest was conducted in October 1980, posttest in May 1981, follow-up test in October
1981.
Outcomes
Attrition (on overall): 15%.
4 students from the experimental condition and 1 student from the control condition
were deleted from the analysis because they reported significant use of a bogus drug.
Notes
Pgina 34
Ringwalt 1991 Study
RCT.
Quality Class: B.
Schools were randomly assigned to receive DARE or to be placed in control condition.
Methods
1402 5th and 6th-grade students from 20 North Carolina elementary schools (USA).
1988-1989 school year.
Participants
Intervention group: n=685.
Control group: n=585.
Interventions
Students were pretested approximately 1 week before the intervention began. The pre
and post-test consisted of paper-and-pencil questionnaire assessing self-reported use
of alcohol, tobacco, marijuana and inhalants, behavioral intentions regarding these
substances, and selected attitudinal variables hypothesized to be related to drug use
and targeted by the DARE curriculum. All students were post-tested immediately after
the semester-long program.
Outcomes
Attrition (on overall): 9.4%. Analysis sample: n=1270. Notes
Rosenbaum 1994 Study
CPS, partially randomized.
Quality Class: B.
18 schools were matched by school type, ethnic composition, number of students with
limited english proficiency, and the percent of students from low income families; 12
pairs were then randomly allocated to receive the intervention or to be in the control
group, whilst the remaining 6 pairs were allocated using non-random procedure. Multiple
regression approach was employed at the analysis stage to control for race/etnnicity,
sex, year in school, family structure and metropolitan status (urban, suburban or rural).
Methods
1800 students from 36 elementary schools in the Northern Half of the Illinois state
(USA). 1990-1991 school year.
Participants
Interventions
Use of substances, school performance, general and specific attitude toward drugs,
perceived benefits and cost of using drugs, perceived peer attitudes, self-esteem,
assertiveness, peer resistance skills were assessed using specific questionnaires.
Pre-test was administered during February 1991, immediately prior to DARE's
implementation. Follow-up tests were administered one year, 2 years and 6 years after
baseline.
Outcomes
Attrition (on overall) at 1 year: 12%. Analysis sample: n=1584.
Attrition at 2 years: 25.9%. Analysis sample: n=1334.
Attrition at 6 years: 30.3%. Analysis sample: n=1254.
Attrition at 6 years: unclear.
Notes
D Allocation concealment
Pgina 35
Ross 1998 Study
CPS.
Quality Class: A.
The control school was selected to match the experimental school in terms of age and
ethnic background.
At the analysis stage, a multivariate model was used, adjusting for age, gender, family
structure, athmosphere of discussions with parents, peer alcohol and drugs use, parents'
alcohol and drugs use, satisfaction with first use, reasons for use, recreational activities,
pretest differences.
Methods
491 7th-grade students, Quebec (Canada). School year not specified. Participants
Promotion de l'autonomie et de la volont de faire obstacle aux toxicomanies (PAVOT
program), based on psychosocial models of behavior and learning. The classroom
activities consisted of seven 50-minute lessons, four of which provided information
about alcohol and drugs, one was focused on the role of external influences, one
discussed decision making, and one examined the role of peer pressure on young
people. Development of peer pressure resistance tactics, communication and decision
making skills were fostered by observation through modelling.
Experimental group, n=235. Control group, n=256.
Interventions
Pretest was administered before exposure to the program at the beginning of the school
year, and the post test was conducted one year later.
Assessments were performed through a specific self-administered questionnaire.
Outcomes
Attrition at post test: 38% in the experimental school (analysis sample n=145), 30% in
the control school (analysis sample n=179).
Attrition on overall: 34%.
Some evidence of differential attrition.
Notes
Sexter 1984 Study
RCT.
Quality Class: C.
One sixth of the students were assigned at random to the control group in each program,
being later combined in analysis.
Hierarchical multiple regressions were used to associate prevention models with
outcomes.
Methods
1575 students grade 5th through 9th; New York, USA. September 1980 - June 1981. Participants
Five broad categories of prevention programs were analysed.
1. Humanistic education model: prevention programs using activities designed to clarify
values and stimulate thought, opinion making and decision making.
2. Peer group model: programs focused on group formation, problem solving and risk
taking.
3. Parent effectiveness model: programs devoting major resources to teach parents
more effective parenting styles and to improve communication between parents and
children.
4. Network model: prevention groups built around shared common problems and drew
upon members' resources to support each other.
5. Advocacy model: programs focused on providing information to aid in solutions of
problems.
Interventions
Pgina 36
Alcohol, marijuana, psychedelics, CNS stimulants, CNS depressants, glue, solvents
and spray abuse were assessed using a modified version of the New York State survey
of substance abuse, the Periodic Assessment of Drug Abuse among Youth. The survey
was administered to prevention participants at the beginning and the end of each
program, corresponding to the school semester.
Outcomes
No data suitable for inclusion in the meta-analyses. Notes
Sigelman 2003 Study
RCT.
Quality Class: B.
Children were randomly assigned to four intervention groups, within each of the 19
same-grade groupings.
ANOVA and ANCOVA analysis, correcting for correlations between pre-test and
post-test, were performed to evaluate the curriculum effect. In the paper the three
experimental groups were pooled, however we used for the inclusion in the
meta-analyses data for tobacco myths group versus control (data obtained from authors).
Methods
363 students grade 3rd through 6th, from 24 classrooms in 4 metropolitan catholic
schools; USA. School year not specified.
Participants
Four knowledge-focused curricula were implemented.
1. Basic: designed to teach how drugs have their effects
2. Biologically enhanced: basic plus additional information about nervous and circulatory
system.
3. Tobacco myths: basic plus additional segment on short and long term effects of
tobacco use and differences among alcohol, cocaine and tobacco effects.
4. Control: information about flu and chicken-pox transmission, prevention and treatment.
Each child listened to the assigned curriculum on a personal tape recorder, using
headphones, while following along in a workbook. One researcher was randomly
assigned to oversee each group.
Each curriculum lasted one hour per day for three days plus one interactive session
on the last day, when the group leader sat with each group to discuss the workbook
quizzes.
Interventions
Pretest was administered about 6 days before exposure to the program, and the post
test was conducted about 10 days after the program administration.
General biological background knowledge scales and parallel scales measuring
knowledge, attitudes, and intentions regarding alcohol and cocaine were created; 32
scales were constructed.
Outcomes
Attrition at post-test: 7.2%. Analysis sample n=337.
Notes
Snow 1992 Study
RCT.
Quality Class: B.
Classrooms were grouped into homogeneous clusters based on socio-economic status
and ethnicity, and then randomly divided into program and control groups.
Multivariate analysis of variance and logistic regression were used at the analysis stage.
Methods
Pgina 37
1372 6th-grade students from two Southern New England towns, USA. Academic years
1980-81, 1981-82. Follow-up at eight grade, during the spring of 1983 and 1984.
698 students in the Program Group, 674 in the Control Group.
Participants
Cognitive-behavioral skills intervention. 40 minute sessions once per week for 12 weeks.
The sessions were designed to familiarize students with the basic concepts of effective
decision-making, to promote role flexibility, to increase students' abilities to recognize
and manage peer pressure, to enhancve students' ability to turn to others for information
and support when faced with decisions. Teaching techniques included presentation,
brainstorming exercises, discussions and role-plays.
Intervention group, n=698.
Control group, n=674.
Interventions
Improvement of decision-making processes; marijuana use. Assessment were
administered during final intervention session in Program classrooms, while it was
administered a week before or after in Control Groups with a decision-making
questionnaire. Student Drug Use Survey was administered one month after the
completion of the Program, and two years later.
Outcomes
Attrition: 8.9% at posttest.
Attrition: 20.7% at 2-years follow-up: 19.6% for intervention (n=545) and 21.8% for
control group (n=530).
Notes
Sussman 1998 Study
RCT.
Quality Class: B.
Selected schools were blocked by estimates of drug use prevalence, ethnic composition
of the school and the community, student enrollment and standardized achievement
test scores, and were randomly assigned by block to one of the three experimental
conditions.
Methods
1074 students from 21 continuation high school (students who are unable to remain in
the regular school system for functional reasons, including substance abuse when
reaching high school age). California (USA). October 1994 through May 1995.
Participants
The experimental curriculum consisted of 9 sessions with a health motivation-social
skills-decision making approach. The first 3 lessons motivates students to listen to
prohealth programming and provides them with effective listening skills. The second
3 lessons instructed students in chemical dependency issues and alternative coping
skills, whilst the third 3 lessons encourages the students making non-drug-use choices.
Three groups:
- classroom-only program
- classroom plus a school as community program (SAC)
- standard care condition
Interventions
A school-wide pretest survey was conducted at each of the 21 schools immediately
A specific questionnaire was used to collect data about demographic variables, drug
use, socio-economic data, prevalence estimate of peer use, perceived stress, sensation
seeking, and assertiveness measures. Breath samples were collected to evaluate
carbon monoxide content.
Outcomes
Pgina 38
Attrition at one year: 23%. Analysis sample n=1074.
Notes
Sussman 2002 Study
RCT.
Quality Class: C .
Selected schools were blocked by estimates of drug use prevalence, ethnic composition
of the school and the community, student enrollment and standardized achievement
test scores, and were randomly assigned by block to one of the three experimental
conditions. Linear composite scores composed of these variables were created for
each school; adjacent scores were used to form six triplets that then were randomly
assigned to condition.
A generalized linear mixed model with a logit link function for dichotomous outcomes
was applied to correct for cluster effect.
Methods
1037 students from 18 continuation high school (students who are unable to remain in
the regular school system for functional reasons, including substance abuse when
reaching high school age). South California (USA). October 1997 through May 2000.
Participants
The experimental curriculum consisted of 12 sessions of the 9 sessions program already
described in Sussman 1998. To the original program 3 further sessions were added,
focused on marijuana use prevention, tobacco use cessation, and self-control for drug
abuse and violence prevention. A self-instruction version of the curriculum was
developed; during sessions, a health educator was available as a resource to students.
Three groups:
- health educator led condition
- self-instruction condition
- standard care control condition
Interventions
A school-wide pretest survey was conducted at each of the 18 schools immediately
A specific 20-page self-reported questionnaire was used to collect data about
demographic variables, drug use, socio-economic data, prevalence estimate of peer
use, perceived stress, sensation seeking, and assertiveness measures. Breath samples
were collected to evaluate carbon monoxide content.
Students for whom parental response could not be obtained after at least three attempts
were surveyed anonymously at pre-test only.
Two-year follow-up surveys were administered only by telephone and by mail.
Outcomes
Attrition at two years: 44.6%. Analysis sample n=575.
Notes
Valentine 1998 Study
CPS.
Quality Class: C.
A multivariable model was built using logistic regression to adjust for statistically
significant differences between the treatment group and the non-equivalent comparison
group.
Methods
Pgina 39
Students attending a public middle and high school in Boston, Massachusetts (USA)
during the period 1993-1996.
Middle school (analysis sample): 110 (78) high risk students in the intervention group,
135 students in the comparison group.
High school (analysis sample): 227 (109) high risk students in the intervention group,
308 students in the comparison group.
Participants
A treatment student was defined as a student for whom a Client Intake was completed
and documented, who received at least one service from the Urban Youth Connection
program during the study period and for whom both baseline and follow-up survey were
available. A comparison group student is defined as a student who did not participate
in the Urban Youth Connection program during the study period and for whom both
baseline and follow-up surveys are available.
The Program consisted of individual, pair or group counseling provided by graduate
students interns enrolled in a master degree program in educational psychology at a
local university. The counselors were supervised by a clinical supervisor. Students
enetered the program initially through referral from teachers, based upon a risk profile
(academic and behavioural).
Interventions
Self reported 30-day use of alcohol, tobacco and other drugs; self-esteem; social coping;
depression, school attendance and academic performance. All the outcomes were
measured by a 139-items self-administered questionnaire given to treatment and
comparison school students two times per year over the course of the service years
at each site.
Outcomes
Attrition: 29% in the middle school, 52% in the high school (on overall 44.3%).
Unclear selection criteria for intervention and control group.
High risk students in the intervention group, low risk students in the comparison group;
the statistical adjustment performed at the analysis stage could be not sufficient to
minimize the bias.
Lenght of time in the program and follow-up time varied among participants: two surveys
per year were conducted in the study period with the intent of obtaining at least one
baseline and one follow-up survey per student.
Notes
Werch 1991 Study
RCT.
Quality Class: B.
Students were blocked on school and grade level, then assigned randomly by class to
either the intervention or the control group.
Methods
511 students from elementary schools in northwest Arkansas (USA), spring 1989. Participants
Keep A Clear Mind Program (KACM).
Students assigned to the intervention group received four weekly lessons, based on a
social skills training model, aimed to help children to develop specific skills to refuse
and avoid "gateway" drug use. Each of the lessons provided and introduction to the
weekly topic, followed by activities to be completed at home with a parent. The lesson
was taught by a project assistant or the classroom teacher. Students were given small
incentives for remembering to return their lessons by the end of the week.
Interventions
Pgina 40
Data were collected from students and parents approximately two weeks before and
after the implementation of KACM.
The student survey measured alcohol, tobacco and marijuana use, intentions, beliefs
and knowledge. Drug-related belief items measured peer pressure susceptibility,
self-efficacy, family expectations not to use drugs, perceived peer use, and motivation
to not use drugs.
Outcomes
Attrition at post-test: 11%.
in the groups and the standard deviations for the means are not given. Authors
contacted: data no more available.
Notes
Characteristics of excluded studies
Reason for exclusion Study
RCT. Randomization failed: selection of schools to be enrolled occurred after the assignment
of the intervention. No attempt of controlling for confounding variables at the analysis stage.
Ambtman 1990
DARE Project.
CPS. No control for confounding variables at the analysis stage. No matching pre-post test.
Becker 1992
CPS. Inadequate control for confounding variables at the analysis stage. Bonaguro 1988
RCT. Follow-up analysis of a subsample of the original study (Botvin 1995, included): only
447 students out of 3597 participating in the original study completed the drug use
questionnaire.
Botvin 2000
RCT. Unclear attrition rate. No useful measures investigating drug use. Some evidence of
failure of the randomization procedure.
Bry 1982
RCT - TU DECIDES
Unclear unit of randomization, methods and base population. Unclear individual linkage
between assessment and exposure.
Calafat 1984
CPS. Inadequate control for confounding variables at the analysis stage. Cuijpers 2002
CPS. No confounding adjustment. Multiple regression analysis is mentioned but no results
are given. The authors has been contacted and they replied the files were no longer available.
De Jong 1987
RCT. The units of randomization were too limited to assure the validity of the method. No
confounding adjustment at the analysis stage. No data are presented for drug use or mediating
variables.
De La Rosa 1995
CPS. Unclear criteria for selecting high-risk students. DeWit 2000
CPS. Inadequate control for confounding variables at the analysis stage. Unclear individual
linkage between pre and post-test.
Dedobbeleer 2001
Unclear randomization procedure. Process evaluation; high attrition rates (54%). No measure
useful for the review.
Dent 1998
RCT. Unclear methods of analysis; initial random assignment to the groups was not taken
into account at the analysis stage.
Donaldson 1994
CPS. No confounding adjustment. Selection bias. Dukes 1997
RCT. No criteria for selecting students were presented. Intervention consisted in the broadcast
of an interactive CD during a morning session. Post test was carried out the day after the
intervention.
Duncan 2000
Pgina 41
CPS. No confounding adjustment at the analysis stage. Eggert 1990
RCT. Analysis of 3 cohorts (1989, 90, 91 school years); the program offered were different
for the third cohort. The experimental conditions were merged at the analysis stage. Some
evidence of randomization failed. The second paper (Thompson 1997) compared late versus
early cohort effects.
Eggert 1994
CPS. Life Skills Training Program modified.
No confounding adjustment at the analyses stage.
Fraguela 2002
RTO - SMART Project.
CPS. Intervention and control group outcomes were compared with pooled pretest of groups.
Freimuth 1997
SMART Project.
RCT. Analysis of 3 cohorts (1982, 83, 84 school years); the programs offered were different
for the 3 cohorts. The experimental conditions were merged at the analysis stage. 3 years
evaluation of the original study (Hansen 1988, included).
Graham 1990
CPS. Inadequate control for confounding variables. Unclear wether control pupils received
the program.
Green 1989
RCT. Secondary analysis of a subsample of the original study (Botvin 2001, included), based
on risk level.
Griffin 2003
CPS. Inadequate confounding control. Uncertain individual linkage between exposure and
outcomes.
Hansen 1997
CPS. Large social differences among the groups at baseline; at the analysis stage no control
for social variables. Inadequate confounding control.
Harmon 1993
CPS. No confounding adjustment. Kim 1981
CPS. No confounding adjustment. No individual linkage between pre and post-test. Kim 1982
RCT. Unclear methods; some evidence of randomization failure. High attrition rates (51%). Kim 1993
CPS. No confounding adjustment. Kreutter 1991
CPS. Insufficient confounding control. No individual linkage between exposure and outcome
measurements.
Lewis 1972
PRIDE Project.
RCT. Randomization failed. No control of confounding variables at the analysis stage.
LoSciuto 1988
CPS. No confounding adjustment. McAlister 1980
CPS. At the analysis stage, a multivariate model was performed, containing only pretest
scores. Inadequate control for confounding variables.
Moberg 1990
CPS. Incomplete confounding control. High attrition rates. Uncertain individual linkage between
exposure and outcomes.
Moskowitz 1983
Quasi experimental study. The randomization procedure was applied only to a subsample
of the study populatation. Inadequate control for confounding variables at the analysis stage.
O'Donnell 1995
RCT. No results were presented for control group. Olton 1985
Midwestern Prevention Project.
CPS. Multicommunity Trial: it is not possible to separate the effect of the school intervention
from the effect of the community program. 70% of the sample was tracked by a cross-sectional
sampling, including new incoming students who might not have received the intervention.
Pentz 1989
CPS. Relevant baseline differences among groups. No confounding adjustment at the analysis
stage.
Petoskey 1998
Pgina 42
EARLY ALLIANCE Prevention Trial.
CPS. Multicontextual prevention intervention: the effect of the school intervention is compared
with multicontextual (community, family) intervention, no control (usual curriculum) group.
Prinz 2000
CPS. No confounding adjustment. Raynal 1996
KICK Project.
RCT. Unclear randomization procedure; some evidence of failure in randomization. Inadequate
control for confounding factors at the analysis stage.
Rollin1994
CPS. No confounding adjustment. No individual linkage between exposure and outcome
measurements, analysis by class.
Sarvela 1987
RCT. Students enrolled for the study are Native Americans from reservations in USA; the
program is focused on Native American culture, values and traditions.
Schinke 2000
RCT. Randomization failed. No control for confounding variables at the analysis stage.
Unclear attrition rates.
Shope 1996
Subjects assigned to intervention and control group are subsamples of different population
groups.
Short 1998
CPS. The annual change rate in the population is about 20%-30%. After 5 years follow-up,
the population included is different from the population on which outcomes were measured.
Skroban 1999
RCT. Secondary analysis of a subsample of the original study (Gersick 1988, included),
based on students' family household status.
Snow 1997
CPS. Inadequate control for confounding variables. Stevens 1996
Urban Youth Connection.
CPS. Unclear criteria for intervention and control assignment. Unclear methods of control
for confounding variables.
Valentine 1998a
RCT. Randomization failed. No control for confounding variables at the analysis stage. Villalb 1993
CPS. No confounding adjustment. Young 1997
TABLAS ADI CI ONALES
Table 01 Metodological quality of included studies (CDAG's check list criteria): RCTs
cluster
effect adj
class total
score
equal
treatment
similarity
of groups
attrition blinding alloc
concealment
randomisation study
- B 6 yes=1 unclear=0 0%=3 inadequate=0 unclear=1 mentioned=1 Bernstein
1987
- B 7 yes=1 yes=1 9.6-24%=3 inadequate=0 unclear=1 mentioned=1 Botvin
1984-90
- B 6 yes=1 yes=1 25-39.6%=2 inadequate=0 unclear=1 mentioned=1 Botvin
1990-95
- B 7 yes=1 yes=1 16-40%=3 inadequate=0 unclear=1 mentioned=1 Botvin
1994-95
- B 6 yes=1 yes=1 13%=3 inadequate=0 unclear=1 not
mentioned=0
Botvin
1997
yes B 6 yes=1 yes=1 30.6%=2 inadequate=0 unclear=1 mentioned=1 Botvin
2001
Pgina 43
Table 01 Metodological quality of included studies (CDAG's check list criteria): RCTs
- B 6 yes=1 yes=1 7-35%=2 inadequate=0 unclear=1 mentioned=1 Clayton-Lynam
- B 6 yes=1 unclear=0 10-17%=3 inadequate=0 unclear=1 mentioned=1 Cook
1984
- B 7 yes=1 yes=1 23%=3 inadequate=0 unclear=1 mentioned=1 Corbin
1993
yes B 6 yes=1 yes=1 37.1%=2 inadequate=0 unclear=1 mentioned=1 Dent 2001
yes B 6 yes=1 unclear=0 8.8%=3 inadequate=0 unclear=1 mentioned=1 Ellickson
2003
- B 6 yes=1 yes=1 18-40%=2 inadequate=0 unclear=1 mentioned=1 Ellickson-Bell
yes B 6 yes=1 no=0 16%=3 inadequate=0 unclear=1 mentioned=1 Furr-Holden
2004
- B 7 yes=1 yes=1 8.9-20.7%=3 inadequate=0 unclear=1 mentioned=1 Gersick-Snow
- C 5 yes=1 no=0 30-39%=2 inadequate=0 unclear=1 mentioned=1 Hansen
1988
yes B 6 yes=1 no=0 22%=3 inadequate=0 unclear=1 mentioned=1 Hansen-Palmer
- C 3 yes=1 unclear=0 unclear=0 inadequate=0 unclear=1 mentioned=1 Hecht
1993
- B 7 yes=1 yes=1 10.9-17.9%=3 inadequate=0 unclear=1 mentioned=1 Hurry
1997
- B 7 yes=1 yes=1 0%=3 inadequate=0 unclear=1 mentioned=1 Jones
1990
- B 7 yes=1 yes=1 0%=3 inadequate=0 unclear=1 mentioned=1 Jones
1995
- C 3 yes=1 unclear=0 unclear=0 inadequate=0 unclear=1 mentioned=1 Kim 1989
- C 5 yes=1 unclear=0 20-25%=2 inadequate=0 unclear=1 mentioned=1 Malvin
1985
- B 6 yes=1 no=0 15%=3 inadequate=0 unclear=1 mentioned=1 Moskowitz
1984
- B 6 yes=1 no=0 9.4%=3 inadequate=0 unclear=1 mentioned=1 Ringwalt
1991
- C 3 yes=1 unclear=0 unclear=0 inadequate=0 unclear=1 mentioned=1 Sexter
1984
- B 7 yes=1 yes=1 7.2%=3 inadequate=0 unclear=1 mentioned=1 Sigelman
2003
- B 7 yes=1 yes=1 23%=3 inadequate=0 unclear=1 mentioned=1 Sussman
1998
yes C 4 yes=1 yes=1 44.6%=0 inadequate=0 unclear=1 mentioned=1 Sussman
2002-03
- B 7 yes=1 yes=1 11%=3 inadequate=0 unclear=1 mentioned=1 Werch
1991
Pgina 44
Table 02 Metodological quality of included studies (CDAG's check list criteria): CPSs
class total score treatment
descript
groups'
description
losses to
follow-up
confounding
control
population
base
study
B 10 adequate=1 adequate=1 12%=3 partial=3 adequate=2 Rosenbaum-Ennett
A 11 adequate=1 adequate=1 34%=2 adequate=6 partial=1 Ross 1998
C 5 inadequate=0 adequate=1 44.3%=0 partial=3 partial=1 Valentine
1998
Table 03 Characteristics of intervention and control arms
context
activation
booster administerer educ
technique
educ objectiv arms study
low no external
educators
interactive affective (+
knowledge)
intervention Bernstein 1987
low no older peers interactive skills (+ know +
affect)
intervention 1 Botvin 1984-90
low yes formally trained
teachers
interactive skills (+ know +
affect)
intervention E1 Botvin 1990-95
low yes external
educators
interactive skills (+ know) intervention 1 Botvin 1994-95
low no teachers interactive skills intervention Botvin 1997
low yes teachers interactive skills intervention Botvin 2001
low no policeman interactive skills (+ affect) intervention Clayton-Lynam
low no external
educators +
teachers
interactive skills (+ affect) intervention Cook 1984
low no external
educators
skills)
intervention 1 Corbin 1993
low no external
educators
interactive skills intervention Dent 2001
low no formally trained
teachers
interactive skills (+ affect) intervention Ellickson 2003
teachers interactive skills (+ affect) intervention 1 Ellickson-Bell
low no teachers passive skills classroom
centered
Furr-Holden
2004
low no external
educators
interactive skills (+ know) intervention Gersick-Snow
low no teachers +
peer leaders +
external
educators
skills)
affective Hansen 1988
low no external
educators
interactive knowledge information Hansen-Palmer
low no external actors passive unclear film only Hecht 1993
Pgina 45
Table 03 Characteristics of intervention and control arms
low no external
educators
interactive skills (+ affect) intervention Hurry 1997
low no external
educators
skills)
intervention 1 Jones 1990
low no external
educators
skills)
intervention 1 Jones 1995
low no external
educators
interactive skills intervention Kim 1989
low no external
educators
interactive skills (+ affect) intervention 1 Malvin 1985
low no external
educators
interactive skills (+ affect) intervention Moskowitz
1984
low no policeman interactive skills (+ affect) intervention Ringwalt 1991
low no policeman interactive skills (+ affect) intervention Rosenbaum-Ennett
low no teachers
(unclear)
interactive skills intervention Ross 1998
low no external
educators
(unclear)
passive knowledge advocacy Sexter 1984
low no self-administered
+ external
educators
passive/interactive knowledge basic Sigelman 2003
high no external
educators
interactive skills SAC Sussman 1998
low no external
educators
interactive skills health educator
led
Sussman
2002-03
low no external
educators
counselling affective intervention Valentine 1998
high no external
educators or
teachers
interactive skills intervention Werch 1991
Table 04 Results from RCTs not providing data for meta-analyses (1st part)
main results measured outcomes study
favour intervention perceived riskiness (post) Bernstein 1987
no significant differences knowledge (post) affective (+knowledge) vs control
no significant differences self-reported behavior (post) (intervention arm: interactive)
favour intervention (peervs teacher,
peer vs control)
marijuana use (post) Botvin 1984-90
favour intervention (peer vs control,
teacher vs control, peer vs teacher )
marijuana knowledge (post) skills (+knowledge+affective) vs control
Pgina 46
favour intervention (peer vs control,
peer vs teacher )
marijuana attitudes (post) 4 intervention arms: peers vs teachers
and booster vs not
lower in peer-led vs teacher-led locus of control (post) (intervention arms: all interactive)
favour formally and videotape trained
teachers vs control
marijuana use (3 years) Botvin 1990-95
favour formally trained teachers marijuana knowledge (3 years) skills (+knowledge+affective) vs control
favour videotape trained teachers marijuana attitudes (3 years) 2 intervention arms: formally vs
videotape trained teachers vs control
lower in formally trained teachers adult marijuana use (3 years) (intervention arms: all interactive)
no significant differences marijuana use (2 years) Botvin 1994-95
no significant differences intention to use marijuana (2 years) skills (+knowledge)(+affective) vs
knowledge
favour information-only control group marijuana knowledge (2 years) 2 intervention arms: skills+knowledge,
educators vs skills+affective, peer vs
knowledge, educators
no significant differences marijuana attitudes (2 years) (intervention arms: all interactive)
favour intervention marijuana use (post) Botvin 1997
favour intervention current drug use (post) skills vs control
favour intervention intention to use marijuana (post) (intervention arm: interactive)
no significant differences marijuana use (1 year) Clayton-Lynam
favour intervention attitudes towards drugs (1 year) skills (+affective) vs control
favour intervention attitudes towards marijuana (1
year)
(intervention arm: interactive)
no significant differences drug use (1 year) Cook 1984
no significant differences marijuana use (1 year) skills (+affective) vs control
no significant differences opiate use (1 year) (intervention arm: interactive)
no significant differences marijuana use (1 year) Dent 2001
no significant differences hard drugs use (1 year) skills vs control, intervention arm:
interactive
lower in interventions peer marijuana use (post) Ellickson-Bell
favour peer leader group vs control intention to use marijuana (post) skills (+affective) vs control
lower in interventions peer marijuana use (1 year) 2 intervention arms: peers vs not
favour peer leader group vs control intention to use marijuana (1 year) (intervention arms: all interactive)
favour control vs affective, favour social
vs control
marijuana use (1 year) Hansen 1988
favour control vs affective marijuana use (2 years) affective (+skills) vs skills vs control
(intervention arms: all interactive)
favour normative education vs
information (skills vs knowledge)
marijuana use (1 year) Hansen-Palmer
Pgina 47
no significant differences resistance
training vs information (skills vs
knowledge)
marijuana use (1 year) knowledge vs skills (knowledge) vs
skills (knowledge) (intervention arms:
all interactive)
favour intervention marijuana use (post) Hecht 1993
favour intervention hard drugs use (post) skills (+affect) vs control (2 intervention
arms interactive, 2 passive)
Table 05 Results from RCTs not providing data for meta-analyses (2nd part)
no significant differences drug knowledge (post) Malvin 1985
no significant differences drug attitudes (post) skills (+affective) vs control
no significant differences soft drugs peer use (post) (intervention arms: all interactive)
no significant differences knowledge (post) Moskowitz 1984
no significant differences soft drugs attitudes (post) skills (+affective) vs control
no significant differences soft drugs peer use (post) (intervention arm: interactive)
favour peer group vs control marijuana use (post) Sexter 1984
favour humanistic education group
(affective) vs control
psychedelics use (post) knowledge or skills or affective vs
control
favour humanistic education group
(affective) vs control
stimulants use (post) (intervention arms: all interactive
except for the affective arm, which is
passive)
no significant differences peer pressure susceptibility (post) Werch 1991
no significant differences self-efficacy (post) skills vs control
no significant differences marijuana knowledge (post) (intervention arm: interactive)
Table 06 Results from CPSs
no significant differences drug attitudes (post) Rosenbaum-Ennett
favour intervention self-esteem (post) skills (+affective) vs control
no significant differences peer pressure resistance (post) (intervention arm: interactive)
no significant differences knowledge (1 year) Ross 1998
no significant differences self-efficacy (1 year) skills vs control (intervention arm:
interactive)
no significant differences (middle school) marijuana use (1-3 years) Valentine 1998
favour control (high school) marijuana use (1-3 years) affective vs control
favour control (middle school) self-esteem (1-3 years) (intervention arm: counselling)
Pgina 48
Table 07 Summary of results at posttest
no differences favour control favour intervention outcome
4 studies drug knowledge
1 study 2 studies marijuana knowledge
1 study 2 studies self-esteem
2 studies self-efficacy
2 studies drug attitudes
2 studies (lower estimate) peers marijuana use
2 studies peers soft drugs use
2 studies peers hard drug use
2 studies intention to use marijuana
1 study 1 study 1 studies marijuana use
Table 08 Summary of results at 1 year follow-up
1 study none 1 study peer pressure resistance
1 study none 1 study self-esteem
1 study none 1 study peers soft drugs use
1 study none 1 study peers hard drugs use
3 studies none none drug attitudes
4 studies 1 study 4 studies marijuana use
Table 09 Summary of results after 2 years follow-up
1 study 1 study marijuana knowledge
1 study 1 study 1 study self-esteem
3 studies self-efficacy
2 studies assertiveness
2 studies decision making skills
2 studies 1 study marijuana attitudes
2 studies drug attitudes
1 study 1 study adult marijuana use
1 study 2 studies peer marijuana use
2 study 1 study peer drugs use
2 studies intentions to use marijuana
5 studies 1 study 1 study marijuana use
Pgina 49
CARTULA
Prevencin del consumo de drogas ilegales en las escuelas. Titulo
Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma
P
Autor(es)
FF, PL y EV conceptualizaron la revisin; FV-T, AZ y EV realizaron las
bsquedas bibliogrficas y organizaron la recopilacin de los artculos. FV-T,
Contribucin de los autores
FF, AB, AZ y EV revisaron los artculos. FV-T, FF y EV extrajeron los datos de
los artculos para el metanlisis. FF redact las secciones: introduccin,
resultados, discusin y conclusiones. FV-T redact las secciones: mtodos,
descripcin de los estudios y calidad metodolgica de los estudios incluidos.
EV redact el resumen y particip en la finalizacin del informe. Todos los
autores proporcionaron comentarios a la versin final.
2001/2 Nmero de protocolo publicado
inicialmente
2004/2 Nmero de revisin publicada
inicialmente
04 febrero 2005
Fecha de la modificacin ms
reciente"
08 febrero 2005
"Fecha de la modificacin
SIGNIFICATIVA ms reciente
El autor no facilit la informacin Cambios ms recientes
El autor no facilit la informacin
Fecha de bsqueda de nuevos
estudios no localizados
Fecha de localizacin de nuevos
estudios an no
incluidos/excluidos
Fecha de localizacin de nuevos
estudios incluidos/excluidos
Fecha de modificacin de la
seccin conclusiones de los
autores
Pgina 50
Prof Fabrizio Faggiano MD
Associate Professor
Department of Medical Sciences
University of Piemonte Orientale "A.Avogadro"
Via Solaroli 17
Novara
28100
ITALY
Tlefono: +39 0321 660661
E-mail: fabrizio.faggiano@med.unipmn.it
Facsimile: +39 011 480633
Direccin de contacto
CD003020 Nmero de la Cochrane Library
Cochrane Drugs and Alcohol Group Grupo editorial
HM-ADDICTN Cdigo del grupo editorial
RESUMEN DEL METANLI SI S
01 conocimiento versus currculo habitual
Tamao del efecto Mtodo estadstico N de
participantes
N de
estudios
Resultado
0.91 [0.42, 1.39] Diferencia de medias
estandarizada (efectos
aleatorios) IC del 95%
220 3 01 conocimiento sobre las drogas
-0.06 [-0.60, 0.47] Diferencia de medias
55 2 02 habilidades para la toma de
decisiones
55 2 03 seguridad en s mismo
ponderada (efectos fijos) IC
del 95%
165 1 04 actitudes hacia la cocana
del 95%
165 1 05 intencin de consumir cocana
02 habilidades versus currculo habitual
participantes
N de
estudios
Resultado
del 95%
decisiones
Pgina 51
02 habilidades versus currculo habitual
484 2 03 autoestima
2.05 [1.24, 3.42] Riesgo Relativo (efectos
120 1 04 resistencia a la presin de los
compaeros
0.11 [-1.09, 1.31] Diferencia de medias
del 95%
367 1 05 actitudes hacia las drogas
120 1 06 intencin de consumir drogas
2371 2 07 consumo de drogas
7287 4 08 consumo de marihuana (todos
los estudios)
fijos) IC del 95%
6916 3 09 consumo de marihuana (slo
estudios de calidad A-B)
5185 3 10 consumo de marihuana
370 1 11 consumo de inhalantes
del 95%
3434 1 12 consumo de inhalantes
746 2 13 consumo de drogas duras
03 habilidades versus conocimiento
participantes
N de
estudios
Resultado
del 95%
decisiones
del 95%
del 95%
445 1 04 autoestima
Pgina 52
03 habilidades versus conocimiento
472 2 05 eficacia individual
del 95%
445 1 06 intencin de consumir
marihuana
del 95%
04 habilidades versus respuesta afectiva
participantes
N de
estudios
Resultado
del 95%
del 95%
05 respuesta afectiva versus currculo habitual
participantes
N de
estudios
Resultado
decisiones
06 respuesta afectiva versus conocimiento
participantes
N de
estudios
Resultado
del 95%
decisiones
Pgina 53
06 respuesta afectiva versus conocimiento
07 tcnica interactiva versus pasiva
participantes
N de
estudios
Resultado
del 95%
decisiones
del 95%
del 95%
445 1 04 autoestima
del 95%
marihuana
del 95%
0.78 [0.49, 1.23] Odds-ratio (efectos fijos) IC
del 95%
382 1 08 consumo de marihuana
0.43 [0.19, 0.99] Odds-ratio (efectos fijos) IC
del 95%
09 compaeros versus educadores externos
participantes
N de
estudios
Resultado
-3.42 [-6.81, -0.03] Diferencia de medias
del 95%
del 95%
decisiones
del 95%
Pgina 54
09 compaeros versus educadores externos
del 95%
515 1 04 autoestima
del 95%
del 95%
marihuana
del 95%
GRFI COS Y OTRAS TABLAS
Fig. 01 conocimiento versus currculo habitual
01.01 conocimiento sobre las drogas
01.02 habilidades para la toma de decisiones
Pgina 55
01.03 seguridad en s mismo
01.04 actitudes hacia la cocana
01.05 intencin de consumir cocana
Pgina 56
Fig. 02 habilidades versus currculo habitual
02.03 autoestima
Pgina 57
02.04 resistencia a la presin de los compaeros
02.05 actitudes hacia las drogas
02.06 intencin de consumir drogas
Pgina 58
02.07 consumo de drogas
02.08 consumo de marihuana (todos los estudios)
02.09 consumo de marihuana (slo estudios de calidad A-B)
Pgina 59
02.10 consumo de marihuana
02.11 consumo de inhalantes
02.12 consumo de inhalantes
Pgina 60
02.13 consumo de drogas duras
Fig. 03 habilidades versus conocimiento
Pgina 61
03.04 autoestima
Pgina 62
03.05 eficacia individual
03.06 intencin de consumir marihuana
Pgina 63
Fig. 04 habilidades versus respuesta afectiva
Fig. 05 respuesta afectiva versus currculo habitual
Pgina 64
Fig. 06 respuesta afectiva versus conocimiento
Pgina 65
Pgina 66
Fig. 07 tcnica interactiva versus pasiva
Pgina 67
07.04 autoestima
Pgina 68
07.08 consumo de marihuana
Pgina 69
Fig. 09 compaeros versus educadores externos
Pgina 70
09.04 autoestima
Pgina 71
Pgina 72

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Faggiano F, Vigna-Taglianti FD, Versino E, Zambon A, Borraccino A, Lemma P

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